Provider Consultant

Overview

Performs compliance audits based on current CMS, CPT, ICD-10 guidelines, as well as all state and federal regulations. Utilizes the CMS 95/97 or 2021 documentation guidelines for evaluation and management (E&M) reviews. Writes and presents concise recommendation worksheets with appropriate findings and references to clients during summation calls. Writes Executive Summaries and must communicate with different levels within the practice/facility. Utilizes review databases (Intelicode, MD Audit, etc).

Required Skills and Experience

• High School diploma with at least one AAPC credential; CPC preferred
• Minimum 5 years review experience in a multispecialty clinic/facility
• ICD-10-CM training
• Computer proficiency, able to research coding questions and utilize HIA’s internal educational resources
• Experience using Electronic Health Record (EHR)
• Independent, focused individual able to work remotely
• Sound organizational, communication and critical thinking skills

Responsibilities

• Prepares for Review
• Reviews Evaluation and Management codes based on CMS 95/97 or 2021 Documentation Guidelines
• Reviews records assigned to ensure appropriate diagnosis reporting based on ICD-10-CM Guidelines (addition, deletion, revision, re-sequence)
• Reviews records assigned to ensure appropriate CPT reporting based on CPT coding conventions
• Reviews record for documentation opportunities and compliance issues based on Federal and State guidelines and/or Payor requirements
• List out findings with recommendations from guidelines/regulations (CMS Documentation Guidelines, Coding Clinic, Federal Regulations, CMS Physician Services Guidelines, etc.) to provider client with educational feedback for corrective action
• Research State/Federal and/or Payor guidelines to support recommendations made
• Uses various software applications, groupers, encoders and other coding tools to analyze and ensure appropriate codes, sequencing and edits
• Runs preliminary and final reports as required
• Completes client rebuttals and makes appropriate changes in database as needed
• Prepares for Summation Conference using Teams
• Conducts Summation Conference with Administration
• Conducts Summation Conference with staff and or providers as requested

Client Relations

• Maintains adequate communication with client throughout the review process to ensure review goals and objectives are met
• Leads organized summation conference in an approachable, educational manner for client staff
• Provides ongoing educational support to client staff between scheduled reviews by researching issues and responding promptly to client inquiries
• Maintains strict confidentiality and adheres to HIPAA guidelines
• Exhibits professional demeanor at all times
• Maintains communication by responding promptly to Corporate office staff
• Demonstrates flexibility, open mindedness, and versatility in adjusting to changing environments
• Handles constructive feedback with a positive attitude
• Receptive to suggestions for changing or improving the way work is accomplished
• Commits to continually improving his/her job skills (i.e. attends educational meetings)