Coding Compliance Specialist

At Virginia Garcia Memorial Health Center, we welcome diversity; we encourage, uplift, and are honored to serve people who have been historically underrepresented and underserved. Our mission is to provide high-quality, culturally appropriate healthcare to low-income residents of Washington and Yamhill Counties, with a special emphasis on seasonal and migrant farm workers and others with barriers to receiving healthcare. We strive to provide an inclusive environment that welcomes and values the diversity of the people we employ and serve.

Job Summary

The role of the Coding Compliance Specialist is to maintain organizational compliance with coding and medical record documentation. The person holding this position is responsible for reviewing the coding of professional services records for compliance with CMS, AMA and certified coding standards. This position will conduct internal chart audits, encounter form reviews, assists with teaching providers and staff coding and reporting results. This position will support any third party billing staff in areas related to coding or collections.

Essential Duties and Responsibilities

• Ensure the medical claims are submitted accurately and in a timely manner by:
• Reviewing electronic health records to assign accurate ICD-10-CM and CPT/HCPCS codes based upon coding principles and official guidelines.
• Reviewing patient records documentation to ensure that services provided are accurate and meet guidelines.
• Monitoring billing performances to ensure optimal reimbursement while adhering to regulations prohibiting unbundling and other questionable practices; prepares periodic reports for clinical staff identifying unbilled charges due to inadequate documentation.
• Utilizing advanced knowledge of medical codes and coding procedures to assign and sequence appropriate diagnostic /procedure billing codes, in compliance with third party payer requirements.
• Interacting with patient care providers regarding billing and documentation policies, procedures and regulations; obtains clarification of conflicting or non-specific documentation.
• Monitoring external data sources to ensure receipt and analysis of all charges (EOBs).
• Reviewing and resolving the claim edit and charge review work queues.
• Assures compliance with all regulatory agencies and payer sources:
• Regular compliance auditing and monitoring payers.
• Creating reports of audit findings under the direction of the Billing Manager.
• Performing audits and analyses of payer denials; providing information on compliance issues arising from audits and formulates recommendations to providers regarding improving documentation practices.
• Assures that providers and support staff have an understanding of their responsibility for accuracy of patient registration and coding of encounters.
• Lead or assist in developing education programs for providers around coding.
• Researching inquiries from providers and patients about fees, reimbursements and denials.
• Acting as a liaison between the Lead Providers, members of senior leadership and the billing department.
• Work with OCHIN to remedy billing problems.
• Interacting with department heads and administrative staff regarding implementation of new codes and revision of charge documents.
• Ensuring the integrity of the HCPCS, CPT and ICD-10 codes are maintained in the electronic medical record (EMR).
• Maintains current coding credentials knowledge of State and Federal regulations applicable to coding by attending conferences, workshops and participating in OCHIN Billing Workgroups.
• Handle protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Valid drivers license, reliable transportation, safe driving record and insurance coverage required.
• Perform other duties as assigned.

HIPAA Requirements

The Coding Compliance Specialist has access to PHI to create and maintain an accurate and up-to-date health record. Applying the minimum necessary standard of HIPAA, the designated record sets to which this employee will have access include all sections of the dental and medical record, patient demographic information in the practice management system, incoming records, reports, results, consultations, etc.

The [position title] should read the content of these records only to the extent needed to accomplish the assigned task (e.g. filing or disclosure).

Knowledge, Skills and Abilities Required

• Knowledge of auditing concepts and principals
• Knowledge of patient care charts and patient histories
• Ability to analyze complex medical records and identify billable services.
• Ability to maintain quality and safety standards.
• Knowledge of current and developing issues and trend in medical coding procedure requirements.
• Advance knowledge of medical coding procedures, systems, and regulatory issues within a specified area of medical specialty.
• Knowledge of anatomy and physiology
• Analytical and problem solving skills
• Ability to gather data, compile information and prepare reports
• Knowledge of medical terminology
• Knowledge of ICD-9CM, ICD-10CM, and CPT-4 coding.
• Ability to clearly communicate medical information to professional practitioners and/or the general public.
• Demonstrated ability to work effectively in a team environment
• High level of accuracy with numbers and data, which will become patient records
• Excellent interpersonal, oral, non-verbal and written communication skills
• Microsoft office suite including Microsoft Word, Excel, PowerPoint and database software
• Commitment and alignment to Virginia Garcias mission, vision and values
• Bilingual/bicultural proficiency (Spanish/English spoken and written) desirable

Education and Experience Required

• High School Diploma or GED and certificate of successful completion of a coding exam is required.
• Certification procedural coder (CPC, CPC-H, CCS, CCSP), accredited records technician (ART) or as a registered health information technician (RHIT).
• Minimum of one year of experience working with Electronic Health Record and specialty coding.
• At least two years experience directly related to the duties and responsibilities specified in the job description.
• Additional education and training is desirable with two year medical office experience and training.
• Billing experience and chart auditing experience preferred.
• Community health experience desirable.
• Valid Oregon drivers license, reliable transportation, safe driving record and insurance coverage required.

Behavioral Competencies

• Accountability: Role model VGs mission, vision, and shared values
• Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations
• Teamwork: If someone needs help, help them
• Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work
• Confidentiality: Maintain strict confidentiality and respect the privacy of others
• Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work
• Respect: Demonstrate consideration and appreciation for co-workers and patients
• Communication: Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others

Physical Requirements

• Standing: 10%
• Walking: 10%
• Sitting: 75%
• Reaching/stooping/bending: 5%
• Must be able to lift/carry up to 25 lbs.
• Computer usage: 75%
• Travel: Occasional travel to clinics and migrant worker camps.

Working Environment/Physical Hazards

• Work in a well-lighted, ventilated environment
• No exposure to blood borne pathogens or hazardous chemicals
• Must be able to handle fast paced work environment with multiple time-sensitive competing demands.

Equipment Used

• Computer
• Telephone
• Fax/copier/scan

Immunization

Staff members must meet immunization requirements as stated in VGMHCs immunization policy and state and federal guidelines.

Job descriptions represent a general outline of the essential and major job duties, functions and qualifications required. They cannot be all-inclusive and comprehensive due to the dynamic nature of work performed to accomplish VGMHCs Mission.

VGMHC is an Equal Opportunity Employer. No person is unlawfully excluded from consideration for employment because of race, color, religious creed, national origin, ancestry, sex, age, veteran status, marital status, or physical challenges. The policy applies not only to recruitment and hiring practices, but also includes affirmative action in placement, promotion, transfer, rate of pay, and termination.