Hospital Coding Quality Specialist - Outpatient Denials

Department :

10393 Enterprise Revenue Cycle - Coding & HIM Support Facility / HIM

Status : Full time

Benefits Eligible : Yes

Hou rs Per Week : 40

Schedule Details / Additional Information :

First Shift

Remote Opportunity

Experience in Hospital Based Outpatient Surgical Coding desired.

Pay Range

$28.05 - $42.10

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 :

Education Required :

Experience Required :

Knowledge, Skills & Abilities Required :

Physical Requirements and Working Conditions :

Our Commitment to You :

Advocate Health offers a comprehensive suite of Total Rewards : benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including :

Compensation

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About Advocate Health

is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names in Illinois; in the Carolinas, Georgia and Alabama; and in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.