HIM Coding Editor Specialist I

Must have experience with resolving edits and denials for Hospital Billing Services.

Primary Purpose

As a part of our Coding Quality team, our coding editors plan an integral role of reviewing coding quality alerts and/or billing edits for hospital, outpatient and ambulatory encounters. Providing a great review and oversight of opportunities before final billing. This team will also review coding denials and evaluate areas of improvement through out the revenue cycle process.

MINIMUM SPECIFICATIONS

Education

• Must have successfully completed an approved coding program OR
• Must be a graduate of a Health Information Management program.

Experience

• Must have five years of coding experience in an acute care hospital environment.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience in lieu of specific education and/or experience as stated above.

Certification/Registration/Licensure

• Because of the lag in SCCE, HCCA, NCRA, and AHIMA updating the status of certifications, current employees whose certification is granted through one of these associations are allowed up to seven (7) calendar days, after expiration, to provide proof of renewal. Although an additional seven (7) calendar days is allowed to provide proof of renewal, there cannot be a lapse in the certification's 'active' status.
• Must be certified through the American Health Information Management Association as one of the following:
• Registered Health Information Management Technician (RHIT)
• Registered Health Information Management Administrator (RHIA)
• Certified Coding Specialist (CCS)
• Certified Coding Specialist 'Physician Based (CCS-P)
• OR
• Must be certified through the American Association of Procedural Coders as one of the following:
• Certified Professional Coder-Hospital (CPC-H)
• Certified Professional Coder (CPC)

Skills or Special Abilities

• Must be able to demonstrate advanced knowledge of coding and abstracting skills.
• Applicants must pass applicable coding test with an 85% or above prior to placement into position. Current Parkland employees requesting reassignment into role must have applicable coding test on file.
• Must be able to demonstrate knowledge of reimbursement (Medicare and Medicaid) principles.
• Must have extensive knowledge of medical terminology, the human disease process, anatomy and physiology.
• Must be able to demonstrate good organizational and leadership skills.
• Must be able to communicate effectively, both orally and in writing.
• Must be able to demonstrate knowledge of computer software applications including MS Office.

Responsibilities

• Verifying accuracy of assigned CPT codes for complex and/or error prone procedures.
• Verifying diagnosis coding accuracy for complex and/or error prone encounters.
• Reviewing charge and procedure mismatches
• Reviewing codes with revenue integrity edits for NCD/LCD coverage
• Reviewing invalid codes, code conflicts and missing modifiers.
• Working with other teams in billing, revenue integrity, coding operations, coding compliance and other revenue cycle counter parts.
• Combining codes for payment window encounters
• Assisting with resolution of accounts with HIM/Coding unbilled hold reasons preventing final billing.
• Validating certain discharge dispositions.
• Assigns appropriate diagnosis and procedure codes, and codes all inpatient and/or outpatient episodes of care recorded in the patient record, including review for APC/MS-DRG options, according to ICD-9-CM /ICD-10 conventions and guidelines, determining secondary diagnoses which meet reporting criteria, and referring to coding references to ensure accuracy of medical records, facilitate record transfer for billing and/or optimize reimbursement for patient care rendered. May assist other coders by training and advising on coding and abstracting according to ICD-9-CM conventions and guidelines, responding to coding inquiries, reviewing and noting coded charts, providing feedback and monitoring chart corrections to ensure that noted changes have been made to facilitate coding consistency, accuracy, efficiency and appropriate billing and reimbursement.
• Assist in resolving billing edits that are holding patient claims from billing, by reviewing claims information, medical records and other applicable documentation. Assists with work flow, priorities for work completion, and communicating workflow issues to the supervisor. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements and monitors results as appropriate in support of the overall goals of the department and Parkland.
• Serves as a liaison between management, coders, physicians, nurses, medical staff, Patient Financial Services, and hospital employees regarding Correct Coding Initiatives, medical necessity and revenue and coding edit issues. Communicates with physicians and nurses by telephone or in writing to clarify documentation issues by obtaining missing diagnoses, procedures or information, resolving ambiguous coding episodes to ensure that missing information is corrected and resubmitted for payment.
• Maintains a positive working relationship to ensure that medical record information is documented and coded according to established conventions and Parkland's policies and guidelines.
• Assist in the identification and reporting of potential quality issues. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the coding and abstracting of medical records. Develops root cause analysis that identify systematic issues. Analysis details of benchmarking and creates resolution of the edits. Develops effective internal controls and monitor reports. Promote adherence to applicable state/federal laws, and the program requirements of accreditation agencies and federal, state, and private health plans. Seeks advice and guidance as necessary to ensure proper understanding.
• Ensure unbilled items are addressed properly and timely. Maintains departmental quality standards, prepares and submits productivity logs to supervisor, as required.
• Identify and review charging, coding, and clinical documentation issues. Stays abreast of the latest developments, advancements, and trends in the field of coding and abstracting of medical records by attending in service training, coding meetings, seminars/workshops, actively participating in professional organizations, and maintaining licensure. Integrates knowledge gained into current work practices.
• This position is 100% Virtual. Virtual employees must also comply with all Parkland policies and procedures governing the use of Parkland information resources. Virtual employees must maintain all equipment lent by Parkland for performing the agreed upon job duties in good working condition. All employment responsibilities and conditions in applicable Parkland policies and procedures apply to employees while working virtually.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.