Claim Review Specialist

About Us Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Job Summary Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product. Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team. Client education, written FAQ answer preparation, and other duties as assigned. Location & Status Remote USA; work from home office. Full time, exempt. Essential Duties and Responsibilities Become proficient in the use of the PARA Data Editor, our proprietary software. Select and review claims for review based on trends/data analysis in the PARA Data Editor; organize information and access to medical documentation. Audit all aspects of claim including omitted or incorrect charges, review OPPS and CAH charges and apply guidelines, CMS/Payer specific guidelines, coding accuracy for ICD-10 CM, CPT/HCPCS (including but not limited to knowledge of rev codes, HCPCS, MUE and CCI edits, UoS and ICD-10 CM). Perform departmental review for inaccuracies, omitted data/documentation and charges. Apply NCCI edits, MUE edits, Medi-Cal and Medicare guidelines/CMS Manual guidance. Identify units of services for E/M Profee/Facility and record documentation improvement. Assist in preparing written documents for publication under guidance of the Director, HIM (e.g., Q&A entries). Develop a working understanding of the outpatient hospital reimbursement process, including documentation, coding, and billing. Participate in presentations to clients and prospective clients, typically over web meetings. Maintain current certifications and accreditations (as applicable). Research new guidelines, data elements, payer specifications, etc. Other duties may be assigned as necessary. Qualifications 5+ years of directly related experience. Expert knowledge in revenue cycle and outpatient coding (ER, SDS, OBS, ancillary, IR, Profee, E/M facility, I&I). CCS, COC or CPC certification required. Medical terminology and anatomy knowledge required. Clinical documentation and inpatient coding experience preferred; new hires will be expected to learn IP during employment. Strong understanding of revenue cycle, CMS Manual/guidelines, Medicaid guidelines. Strong Microsoft Excel, PowerPoint, Word and OneNote skills. Strong understanding of official coding guidelines, OP coding and billing (including rev codes, HCPCS, MUE and CCI edits, UoS and ICD-10 CM). Strong analytical capability, independent thinker and good decision-making skills. Excellent written and verbal communication and presentation skills. Strong computer and technology knowledge and skills. Highly professional demeanor, great client satisfaction skills. Physical Demands Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye–hand coordination and manual dexterity are required to operate office equipment. The ability to perform work at a computer terminal for 6–8 hours a day in an environment with constant interruptions is required. At times, Team Members may be required to sit for prolonged periods and lift up to 20 lbs. Stress may increase during periods of increased activity and multiple deadlines. #J-18808-Ljbffr