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Healthcare Coding Compliance Specialist

2 months ago

Silver Spring, Maryland, United States Children's National Hospital Full time


The Healthcare Coding Compliance Specialist exhibits proficiency in coding and billing adherence while conducting audits to assess the billing accuracy of professional and facility/technical fees. This role includes identifying and rectifying documentation, coding, and billing discrepancies, as well as evaluating the medical necessity of billed services.

Audits involve a thorough examination of the sufficiency and precision of documentation supporting billed services, including ICD-10/CPT/HCPCS codes, DRG and EAPG classifications, medical necessity assessments, reimbursement discrepancies, and compliance with various documentation, coding, and billing standards.

The Specialist employs a standardized audit scoring system to consistently assess documentation and coding, alongside a standardized methodology for reporting audit outcomes.


Qualifications:
  • Minimum Education: Associate's Degree. Candidates with three years of coding experience may be considered in lieu of the degree requirement.
  • Minimum Work Experience: Two years as a Certified Coder, preferably with pediatric coding experience or experience conducting coding audits within a healthcare setting.

Required Skills/Knowledge:

  • Ability to interpret and apply documentation and coding regulations, along with charge capture and reimbursement methodologies.
  • Plan, execute, and conduct coding audits effectively.
  • Collaborate with administrative staff, departmental personnel, and healthcare providers.
  • Manage diverse and competing priorities and projects efficiently while meeting deadlines.
  • Maintain up-to-date knowledge of healthcare billing and coding compliance requirements, practices, and trends.
  • Conduct detailed coding audits, make independent decisions, and prepare comprehensive reports of findings.
  • Interpret medical records, progress notes, handwritten and electronic entries, provider orders, and related documentation.
  • Proficient in using personal computers with Windows operating systems, including Microsoft applications such as Word, Excel, Outlook, PowerPoint, and Access.
  • Effective verbal and written communication skills.

Required Licenses and Certifications:

  • CCS, CIC, CPC, CPC-H, or COC (Required).
  • CPMA and/or CEMA/C or the ability to obtain within six months of starting.

Functional Accountabilities:

  • Conduct scheduled and unscheduled independent audits of professional fee documentation, coding, and medical necessity related to service providers.
  • Perform specialized and focused audits, evaluating the appropriateness and medical necessity of billed services based on supporting documentation.
  • Assess the accuracy of ICD-10, HCPCS, and CPT codes, along with modifier usage and charge capture.
  • Determine overpayments and underpayments and conduct related analyses.
  • Adhere to established audit timelines and protocols, assisting in the development of the audit schedule.
  • Identify services for auditing and apply consistent billing audit methodologies for sample selection, scoring, and reporting.
  • Report findings in a standardized format by established deadlines to ensure proper communication.
  • Stay informed about current Medicare, Medicaid, and other third-party payer billing and documentation requirements.
  • Meet departmental expectations regarding daily productivity and deadlines.
  • Create educational materials for clinical and non-clinical staff.
  • Perform other duties as assigned.

Organizational Accountabilities:

  • Organizational Commitment/Identification: Anticipate and respond to customer needs, following up until needs are met.
  • Teamwork/Communication: Demonstrate collaborative and respectful behavior, partnering with team members to achieve goals.
  • Performance Improvement/Problem-solving: Contribute to a positive work environment, demonstrating flexibility and willingness to change.
  • Cost Management/Financial Responsibility: Utilize resources efficiently and seek cost-effective methods.
  • Safety: Speak up when unsafe behaviors are observed, validate information for decision-making, and promote safety for all.