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Compliance Coding Specialist

2 months ago

Silver Spring, Maryland, United States Children's National Health System Full time
Job Overview - Compliance Coding Specialist

Position Summary
The Compliance Coding Specialist exhibits a high level of proficiency in coding and billing regulations while conducting audits to assess the accuracy of billing practices for both professional and facility/technical fees. This role involves identifying and rectifying documentation, coding, and billing discrepancies, as well as evaluating the medical necessity of billed services.

Key Responsibilities
Audits include a thorough review of documentation adequacy and accuracy supporting billed services, including ICD-10, CPT, HCPCS, and other third-party payer codes, as well as DRG and EAPG assignments. The specialist will:
  • Assess the medical necessity of services rendered.
  • Identify reimbursement discrepancies, including overpayments and underpayments.
  • Ensure compliance with documentation, coding, and billing standards.

Audit Methodology
The Compliance Coding Specialist employs a standardized audit scoring system to consistently evaluate documentation and coding practices, utilizing a structured approach to report findings.

Qualifications
Education:
Associate's Degree required; candidates with three years of coding experience may be considered in lieu of a degree.

Experience:
A minimum of two years as a Certified Coder is required, with a preference for experience in pediatric coding or coding audits within an academic medical environment.

Essential Skills:
  • Ability to interpret and apply coding regulations and documentation standards.
  • Experience in planning and executing coding audits.
  • Strong collaboration skills to work effectively with administrative and clinical staff.
  • Capability to manage multiple priorities and meet deadlines.
  • Up-to-date knowledge of healthcare billing and coding compliance.
  • Proficient in analyzing medical records and related documentation.
  • Strong communication skills, both verbal and written.

Licenses and Certifications:
Required certifications include CCS, CIC, CPC, CPC-H, or COC. CPMA and/or CEMA/C certification must be obtained within six months of employment.

Functional Accountabilities
The Compliance Coding Specialist will:
  • Conduct both scheduled and unscheduled audits of professional fee documentation and medical necessity for service providers.
  • Perform focused audits to evaluate the appropriateness of billed services.
  • Review the accuracy of coding and charge capture in accordance with Medical Center policies.
  • Identify services for auditing and apply consistent methodologies for sample selection and reporting.
  • Maintain knowledge of current Medicare, Medicaid, and third-party payer requirements.
  • Meet productivity targets and deadlines set by the department.
  • Create educational resources for staff regarding coding and billing practices.

Organizational Values
The Compliance Coding Specialist is expected to:
  • Demonstrate commitment to customer service and responsiveness to needs.
  • Foster teamwork and collaborative communication.
  • Contribute to a positive work environment through performance improvement initiatives.
  • Utilize resources efficiently and seek cost-effective solutions.
  • Promote safety and adhere to best practices in all aspects of work.