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POSITION SUMMARY:

Provides clinical coding expertise to Fee For Service Provider Networks (FFS) assuring that the ICD-10 CM/PCS code set and other coding is implemented in a consistent and justifiable manner.  Reviews clinical documentation and diagnostic results to extract data and apply the appropriate ICD-CM/PCS and CPT-4 codes for billing, internal and external reporting, research, and regulatory compliance. Codes inpatient and outpatient conditions and procedures as documented in ICD-CM Official Guidelines for Coding and Reporting and resolves errors associated with billing and claims processing.  Identifies and reports error patterns and designs workflow changes to reduce errors. Coordinates and facilitates annual code updates with program staff.

ESSENTIAL FUNCTIONS:

• Provide medical clinical coding expertise assuring that the ICD-10 CM/PCS code set and other coding is implemented in a consistent, justifiable manner.
• Review clinical documentation and diagnostic results to extract data, and apply the appropriate ICD-CM/PCS and CPT-4 codes for billing, internal and external reporting, research, and regulatory compliance. Codes inpatient and outpatient conditions and procedures as documented in ICD-CM Official Guidelines for Coding and Reporting.
• Resolve errors associated with billing and claims processing; identify and report error patterns; and design workflow changes to reduce errors.
• Coordinate and facilitate annual code updates with program staff.
• Assist in reviewing and validating MMIS ICD-10 modifications.
• Coordinate with program and operations staff and MMIS IT to maintain ICD cross-walk. Ensure code cross-walks are appropriately documented and help resolve mapping discrepancies.
• Reviews provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures. Resolve questions with provider.
• Verify and abstract specific clinical and demographic data, APR-DRG assignment, and APG/EAPG outpatient assignment.
• Assure appropriate diagnosis and grouper assignment. Extract required information from source documentation and enter into system.
• Identify and report non-payment Provider Preventable Conditions (PPC).
• Review error reports and correct or complete missing data elements.
• Act as a resource for staff on coding issues, monitor changes in regulations that impact clinical documentations, reimbursement and coding and disseminate changes in coding rules.
• Ensure that computer systems are maintained with annual code changes and updates.
• Produce clinical data and statistical reports for clinicians, researchers, financial and business planning, and clinical quality support services.
• Review training and communications materials and billing instructions and oversee staff training.

REQUIRED QUALIFICATIONS:

• Bachelors Degree or equivalent.
• 3-5 years coding experience in a health care setting (i.e. hospital, large physician group practice, health plan, etc.)
• Proficient in ICD-9-CM ICD-10-CM/PCS and CPT coding system, DRG, APG, MS-DRG and APCs and official coding guidelines.
• Ability to plan and prepare for ICD-10CM/PCS transition.
• Knowledgeable in medical terminology, anatomy and physiology, abnormal lab results, disease processes, and pharmacology-drug names.
• Basic computer knowledge and familiarity with systems used in healthcare, proficiency with Microsoft Office.
• Excellent organizational and communication skills
• Ability to work independently, and in a matrixed, team oriented, fast paced project environment
• RHIA, RHIT, CCS, or CPC certification