Documentation and Coding Specialist

6 days ago

Stamford, Connecticut, United States Stamford Health Full time
Coding and Documentation Expert

Stamford Health is a leading healthcare system with multiple locations in Connecticut. As a Certified Great Place to Work organization, we understand the importance of attracting top talent to improve our workforce and support our mission. To achieve this, we offer:

  • Competitive salary
  • Sign-on bonuses for designated positions
  • Comprehensive, low-cost health insurance plans available day one
  • Wellness programs
  • Paid Time Off accruals
  • Tax-deferred annuity and (403b) pension plan
  • Tuition reimbursement
  • Free on-site parking and train station shuttle
  • Childcare partnership with Children's Learning Center

This role provides day-to-day coding and documentation education and support to medical providers and coding staff in concert with organizational goals related to correct coding and documentation.

The Coding and Documentation Expert conducts provider coding education along with coding, billing, and documentation audits for accuracy of ICD-10-CM, CPT, HCPCS codes, modifiers, and charges to ensure coding compliance with all regulatory reporting requirements and organizational policies. They serve as a resource to staff for coding questions and support.

Responsibilities

  • Works collaboratively with the Coding Manager and Compliance Team to support the system-wide external audit program by providing remedial and ongoing education to providers focused on identified documentation discrepancies.
  • Works collaboratively with the Coding Manager and Compliance Team in support of new provider onboarding and orientation for Stamford Health physicians and non-physician practitioners.
  • Provides documentation and coding education.
  • Provides input on template development as needed.
  • Audits and reviews documentation in Practice's medical record system with new SHMG providers prior to billing to ensure accuracy and understanding of coding and documentation concepts.
  • Coordinates final approval to release providers from this review with the Coding Manager.
  • Performs internal retrospective, concurrent, or prospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record, and that all coding/documentation combinations are compliant with Federal and State regulations.
  • Researches third-party payer medical and administrative policy that may affect the practice's clinical and billing operations.
  • Assists Manager/Director to communicate changes to physicians, clinicians, office managers, and third-party billing staff.
  • Assists in the development of training materials and presentations for effective provider and staff education.
  • Provides ongoing coding feedback and training to physicians and non-physician practitioners.
  • Reviews physician charge patterns by procedure, diagnosis, denial, insurance type, and other insurance groupings as identified to develop targeted education for physicians and billing staff based on correct coding and third-party payer coverage policy.
  • Maintains knowledge of Physician at Teaching Hospital requirements, Shared Visit, and 'Incident To' billing requirements.
  • Maintains current working knowledge of CPT, HCPCS, and ICD-10 coding principles, government regulations, protocols, and third-party requirements regarding billing and compliance.
  • Consults with physicians and physician staff, as needed, on documentation issues, and other regulatory issues as they arise.
  • Assists in review and assessment of findings from third parties that provide coding validation audits. Formulates and writes appeals when appropriate and/or educates Coder(s) when required.
  • Assists in training new team members of the department on their job role in coding, auditing, and education; provides continued guidance and mentoring as requested by Manager.
  • Prepares audit reports containing adequate evidence to support audit findings and makes recommendations.
  • Presents providers with individualized report results.
  • Identifies and determines that the integrity of coding and revenue generation is supported by the documentation.
  • Escalates issues as appropriate to the Coding Manager, Revenue Cycle Director, providers, clinical staff, coding staff, and other departments and provides recommendations accordingly.
  • Assists in the assessment of impact of current compliance activities and risk evaluation.
  • Participates in decision-making concerning policies and procedures as requested.
  • Creates Monthly Coding Newsletters pertaining to new policies and procedures related to coding and documentation. Providing Coding Newsletters to providers and all SHMG staff.
  • Works closely with providers, leadership, coding staff, and clinical staff. Communicates with providers, clinical staff when needed in order to address all needs and concerns in a timely manner.
  • Shadows providers and works individually and jointly with EMR Implementation Specialists to assist providers in the development of documentation and templates.
  • Participates in committee work and on cross-functional teams as requested by department management.
  • Participate in staff meetings, training, and conference calls as requested.
  • Participates in workshops, seminars, audio conferences, and other educational opportunities to insure continued learning for self-improvement.
  • Seeks out and analyzes opportunities to improve and enhance coding activities among physicians and staff. Provides feedback to Coding Manager.
  • Displays customer service-focused attitude and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence, and commitment to profession.
  • Handles stressful situations with professionalism and tact.
  • Maintains strict patient and physician confidentiality and follows all federal, state, and organization guidelines for release of information.
  • Serves as a resource for department managers, physicians, and administration to obtain information and clarification on accurate and ethical coding standards, guidelines, and regulatory requirements.

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