For assigned coders and providers, review Inpatient, Outpatient or Professional Fee medical records for coding accuracy and medical record documentation as it impacts the correctness of the coding. Provide feedback and deliver additional education to correct inaccurate coding and improve documentation. Essential Job Functions Review medical records for accuracy of coding and data quality. Elements included in reviews may include: All diagnosis and procedure assigned ICD-10-CM and ICD-10 PCS codes Evaluation and Management, CPT, HCPCS Physician Documentation Gaps Adherence to Guidelines Teaching Physician Attestations Clinician Signature Validation Use relevant references to perform the Current Procedural Terminology (CPT-4) Official Coding Guidelines, Coding Clinic, CPT Assistant, CMS guidelines, etc. Communicate effectively with client management, coders, and providers. Provide information regarding work progress, actions, and issues in a timely and effective manner. Create an action plan that articulates strengths and areas that may require ongoing development to ensure an effective and successful program. Assist in creating additional learnings that addresses coding problems and documentation gaps. Solicit feedback from program participants regarding training content or delivery enhancements that would further improve coder/provider effectiveness. Capitalize on electronic delivery avenues. Make recommendations to training content, length, delivery, or other aspects of training based on evaluations and feedback from HIM organization/Provider practice. Keep abreast of training and development research such as learning theory, motivation theory, and new materials, methods, and techniques. Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.
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Job Type
Full-time
Career Level
Senior