Ambulatory Clin Doc Integrity Spec - CFH
About The Position
Performs ambulatory chart review to determine appropriate code assignment based on documentation in the chart to support clinical care provided, including preventives, Medicare Annual Wellness Visits, lowest and highest CPT E/M level, New Patient visits versus Consultation, and medical necessity. Assists in the provision of an efficient and effective clinical coding service within Carle by providing accurate and timely auditing and coding education to providers and coding team members to include CPT E/M coding, CPT Procedural Coding, and ICD10CM coding, as applicable. Ambulatory CDI work closely with HIM leadership and Compliance to assure Carle providers and coding team members are following all regulatory requirements for code assignment. Ambulatory CDI helps identify training needs through ongoing internal provider and staff audits and assists with remediation and reaudit post education. Ambulatory CDIs are responsible for producing coding education materials in formats such as Tips, power point or one to one sessions and group education sessions. Sends out notifications and queries to physicians in the EMR.
Requirements
- Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA)
- Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)
- Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
- Certified Professional Coder - Hospital (CPCH) - American Academy of Professional Coders (AAPC)
- Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC)
- Certified Outpatient Coder (COC) - American Academy of Professional Coders (AAPC)
- Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC)
- Certified Coding Specialist - Physician-Based (CCS-P) - American Health Information Management Association (AHIMA)
- High School Diploma or G.E.D
Responsibilities
- Review quality and completeness of diagnostic and E/M codes with an emphasis on improving documentation.
- Apply comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code assignment.
- Adhere to accepted coding practices, guidelines, and conventions and any pertinent hospital or medical staff policies and guidelines.
- Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
- Provide regular coding reviews and feedback to Carle medical staff and HIM coding team members specific to ICD10CM, CPT E/M or CPT Surgical coding.
- Provide education and education materials related to coding for the coding team members and providers.
- Follow query and notification process and escalates, as necessary.
- Provide statistics around changed and deleted codes to Manager/Director on a regular cadence.
- Escalate results to Compliance as required by audit policy/practice.
- Report compliance or other concerns directly to HIM Director/Vice President HIM as needed or indicated.
Benefits
- Comprehensive benefits package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
