Medical Coding Specialist

Duties:

Reviews medical documentation to perform a variety of coding validations for multiple lines of business under Medicare/TRICARE to determine accuracy of billing and payment. Reassigns and sequences diagnostic and procedural codes using universally recognized coding system as appropriate. Compiles and analyzes statistics to determine focus areas for targeted medical review activities where there is the greatest potential for inappropriate Medicare/TRICARE payments.

• 60% Determines methodology to identify cases for DRG, HIPPS, HCPCS, RUG, and APC validation. Conducts targeted coding, documentation reviews, and validation reviews coordinating rate adjustments and adjudication of corresponding claims. Utilizes Grouper, Rover, MDS QC tool or other appropriate software for code validation.
• 25% Compiles/analyzes statistics to determine focus areas for targeted medical review activities where there is the greatest potential for inappropriate Medicare/TRICARE payments demonstrating records reviewed, outcomes, trends, and savings. Notes deficiencies and makes recommendations to management and others as appropriate/requested. May complete appropriate paperwork/documentation regarding claim/encounter information to correct deficiencies.
• 10% Provides coding guidance to clinical review staff. Develops necessary training or reference materials for review staff.
• 5% Consults with appeals, provider outreach and education and other supported areas of division as needed as a resource for medical records and coding issues.

• Working knowledge of word processing software.
• Knowledge/understanding of medical terminology and medical coding.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.

• Knowledge/understanding of Medicare billing process.
• Working knowledge of spreadsheet and database software.

• Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

• Associate Degree - Health Information Management, OR, Graduate of an Accredited School of Nursing, OR, successful completion of examination offered by American Health Information Management Association (AHIMA) or Academy of Professional Coders (AAPC).

• 1 year either ICD-9, DRG, APC, HIPPS, HCPCS, or RUG coding and validation; or, 2 years: 1 year clinical experience and 1 year in either DRG, APC, HIPPS, HCPCS, or RUG coding and validation.

• Microsoft Office.

• Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) OR Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

• Associate Degree
  - Nursing or Four year degree in Health Information Management.

• 2 years-medical coding experience.