Hospital Coding Quality Specialist - Inpatient

Base pay range

$28.05/hr - $42.10/hr

• Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for outpatient, day surgery and inpatient records. Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions.
• Works collaboratively with coding leadership per their direction in reviewing records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may give visibility into documentation that is driving codes.
• Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed.
• Identifies coder education opportunities, team trends, and consideration of topics to mandate for second level account review before the account is final coded.
• Reviews encounters flagged for second level review, including hospital acquired conditions (HACs), complications and other identified records such as core measures or trends as identified by coding leadership. Performs review of coded encounter for appropriate risk‑adjustment, including accurate severity and risk of mortality assignment.
• Responsible for coding participation in the Clinical Documentation Improvement and Hospital Coding alignment process. Reviews accounts with mismatched DRG assignment following notification from the Inpatient coder, determines the appropriate DRG based on coding guidelines, and provides follow‑up to the clinical documentation nurse with rationale on final outcome. Recommends educational topics for coders and clinical documentation nurses based on observations from reviewing mismatches.
• Participates in hospital coding denial and appeal processes as directed, ensuring timely review and response to any third‑party payer notification of claims where codes are denied. Determines if an appeal will be written based on application of coding guidelines and provider documentation.
• Following review of over payment or underpayment denials, provides appropriate follow‑up to the coding team member and rebilling accounts to ensure appropriate reimbursement. All trends identified are presented to coding leadership timely and logged for historical tracking purposes.
• Investigates and resolves all edits or inquiries from the billing office or patient accounts to prevent any delay in claim submission due to open questions related to coding. Identifies any coding issues as they relate to coding practices and clarifies changes in coding guidance or coding educational materials.
• Maintains continuing education credits and credentials by staying abreast of current knowledge trends, legislative issues and technology in Health Information Management through internal and external seminars. Identifies opportunities for continuing education for the hospital coding team.

• Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA)
• Health Information Administrator (RHIA) registration issued by AHIMA
• Health Information Technician (RHIT) registration issued by AHIMA

• Associate’s Degree in Health Information Management or related field.

• Typically requires 5 years of experience in hospital coding for a large complex health care system, including hospital coding, denial review and/or coding quality review functions.

• Demonstrated leadership skills and abilities.
• Demonstrates knowledge of National Council on Compensation Insurance, Inc. (NCCI) edits, and local and national coverage decisions.
• Expert knowledge and experience in ICD‑10‑CM/PCS, CPT coding systems, G‑codes, HCPCS codes, Current Procedural Terminology (CPT), modifiers, and Ambulatory Patient Categories (APC), MS‑DRGs (Diagnosis related groups).
• Advanced…