HB Coding Denials Integrity Specialist

Health Information Management Specialist

Major Responsibilities:

Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for outpatient, day surgery and inpatient records. Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions.

Works collaboratively with coding leadership per their direction in reviewing records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may give visibility into documentation that is driving codes.

Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed.

Identifies coder education opportunities, team trends, and consideration of topics to mandate for second level account review, before the account is final coded.

Reviews encounters flagged for second level review, including but not limited to; hospital acquired conditions (HACs), complications and other identified records such as core measures or trends as identified by coding leadership. Perform review of coded encounter for appropriate risk-adjustment, including accurate severity and risk of mortality assignment.

Responsible for coding participation in the Clinical Documentation Improvement and Hospital Coding alignment process. Review accounts with mismatched DRG assignment following notification from the Inpatient coder. Determine the appropriate DRG based on coding guidelines. Provide follow up to the clinical documentation nurse with rationale on final outcome. Recommends educational topics for coders and clinical documentation nurses based on their observations from reviewing mismatches.

Participate in hospital coding denial and appeal processes as directed. Ensure timely review and response to any third-party payer notification of claims where codes are denied. Determine if an appeal will be written based on application of coding guidelines and provider documentation.

Following review of overpayment or underpayment denials, provide appropriate follow-up to coding team member as appropriate, rebilling accounts to ensure appropriate reimbursement. All trends identified should be presented to coding leadership in a timely manner and logged for historical tracking purposes.

Investigates and resolves all edits or inquiries from the billing office or patient accounts, to prevent any delay in claim submission due to open questions related to coding. Identifies any coding issues as they relate to coding practices. Clarifies changes in coding guidance or coding educational materials.

Maintains continuing education credits and credentials by keeping abreast of current knowledge trends, legislative issues and/or technology in Health Information Management through internal and external seminars. Identify opportunities for continuing education for hospital coding team.

Licensure, Registration, and/or Certification Required:

• Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA), or
• Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or
• Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA)

Education Required:

• Associate's Degree in Health Information Management or related field.

Experience Required:

• Typically requires 5 years of experience in hospital coding for a large complex health care system, which includes hospital coding, denial review and/or coding quality review functions.

Knowledge, Skills & Abilities Required:

• Demonstrated leadership skills and abilities.
• Demonstrates knowledge of National Council on Compensation Insurance, Inc. (NCCI) edits, and local and national coverage decisions.
• Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, Current Procedural Terminology (CPT), modifiers, and Ambulatory Patient Categories (APC), MS-DRGs (Diagnosis related groups)
• Advanced knowledge in Microsoft Applications, including but not limited to; Excel, Word, PowerPoint, Teams.
• Advanced knowledge and understanding of anatomy and physiology, medical terminology, pathophysiology (disease process, surgical terminology and pharmacology.)
• Advanced knowledge of pharmacology indications for drug usage and related adverse reactions.
• Expert knowledge of coding work flow and optimization of technology including how to navigate in the electronic health information record and in health information management and billing systems.
• Excellent communication and reading comprehension skills.
• Demonstrated analytical aptitude, with a high attention to detail and accuracy.
• Ability to take initiative and work collaboratively with others.
• Experience with remote work force operations required.
• Strong sense of ethics.

Physical Requirements and Working Conditions:

• Exposed to a normal office environment.
• Must be able to sit for extended periods of time.
• Must be able to continuously concentrate.
• Position may be required to travel to other sites; therefore, may be exposed to road and weather hazards.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.