Coding Compliance Specialist

4 weeks ago

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

The Coding Compliance Specialist at Children's National Hospital plays a vital role in ensuring the accuracy and integrity of professional fee documentation, coding, and billing. This position requires expertise in coding and billing compliance, as well as the ability to perform audits to determine billing integrity. The ideal candidate will have a strong understanding of ICD-10/CPT/HCPCS codes, DRG and EAPG assignments, and medical necessity of services billed. Additionally, the candidate should be proficient in the use of personal computers with Windows operating systems, including Microsoft applications such as Word, Excel, Outlook, PowerPoint, and Access.

Responsibilities:

* Perform scheduled and unscheduled independent audits of professional fee documentation, coding, and medical necessity related to professional service providers such as physicians and NPPs (Non-Physician Providers) as well as facility/technical fee billing audits (inpatient and outpatient) as assigned.

* Conducts specialized and focused audits.

* Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation.

* Evaluates the appropriateness of ICD-10, HCPCS and CPT codes, APC/EAPG, DRG, and admission assignments, along with modifier usage.

* Evaluates accuracy of supply and implant charge capture and coding based on Medical Center policies and related payor requirements.

* Makes determinations of overpayments and underpayments and performs other related analysis and evaluations.

* Adheres to the defined audit timeline and audit protocol standards.

* Assists with development of the audit schedule.

* Identifies services to be audited.

* Applies consistent and standardized billing audit methodology for sample selection, scoring and benchmarking development and reporting of findings. Reports findings in standardized format by established deadline so findings can be appropriately communicated.

* Maintains knowledge of current Medicare, Medicaid and other third party payor billing and documentation requirements.

* Meets department expectations about daily productivity targets and deadlines

* Creates educational material for clinical and non-clinical staff.

* Other duties as assigned

Requirements:

* Minimum Education: Associate's Degree or 3 years of coding experience in lieu of the degree requirement.

* Minimum Work Experience: 2 years as a Certified Coder preferably with experience in pediatric coding and/or experience performing coding audits within an academic medical center.

* Required Skills/Knowledge: Interpret and apply documentation and coding rules and regulations along with charge capture and reimbursement methodologies; Plan, conduct and perform coding audits; Work cooperatively with Medical Center administrative staff, department staff, and providers; Manage diverse and conflicting priorities and projects effectively and meet deadlines; Maintain competence in and up-to-date knowledge of healthcare billing and coding compliance requirements, practices and trends; Conduct detailed coding audits, reach independent decisions and logical conclusions and prepare report of findings; Interpret medical records progress notes, hand written and electronic chart entries, provider orders, and other related documentation; Proficiency in the use of personal computers with Windows operating systems including Microsoft applications such as Word, Excel, Outlook, PowerPoint and Access.

* Required Licenses and Certifications: CCS, CIC, CPC, CPC-H, or COC. (Required)

* CPMA and/or CEMA/C or ability to acquire within 6 months after start date. (Required)

Organizational Commitment/Identification:

* Anticipate and responds to customer needs; follows up until needs are met

* Teamwork/Communication:

* Demonstrate collaborative and respectful behavior

* Partner with all team members to achieve goals

* Receptive to others' ideas and opinions

* Performance Improvement/Problem-solving:

* Contribute to a positive work environment

* Demonstrate flexibility and willingness to change

* Identify opportunities to improve clinical and administrative processes

* Make appropriate decisions, using sound judgment

* Cost Management/Financial Responsibility:

* Use resources efficiently

* Search for less costly ways of doing things

* Safety:

* Speak up when team members appear to exhibit unsafe behavior or performance

* Continuously validate and verify information needed for decision making or documentation

* Stop in the face of uncertainty and takes time to resolve the situation

* Demonstrate accurate, clear and timely verbal and written communication

* Actively promote safety for patients, families, visitors and co-workers

* Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

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