Health Information Management Coding Denials Coordinator, FT, Days

Prisma Health•Richland, SC

7d•Onsite

About The Position

Inspire health. Serve with compassion. Be the difference. Job Summary Facilitates, reviews, and writes appeals of key third party denials that involve clinical and/or coding expertise. Performs inpatient coding by assigning ICD-CM and ICD-PCS codes as well as DRG assignment. Ensures the accuracy of patient data by appealing and validating coding and clinical validation denials, in partnership with Revenue Cycle, Coding, Quality, Physician Advisors, and other health care team members. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Formulates and submits letters of appeals for coding and clinical validation denials by providing appropriate clinical documentation, supported by current industry guidelines, medical management standards and protocols. To ensure that the overall quality, level of services, severity of illness, and acuity of care are accurately reflected in a complete medical record, yielding the appropriate reimbursement for the level of services rendered and resources consumed. Adheres to all appeal timelines as prescribed by payer agreements. Applies ICD and ICD-PCS codes including major traumas, and Neonatal Intensive Care Unit (NICU) records based on review of clinical documentation. Verifies assignment of DRGs, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures. Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines. Codes inpatient records periodically based on review of clinical documentation. Ensures the validity and accuracy of ICD coding, Diagnosis Related Group (DRG), Severity of Illness (SOI), Risk of Mortality (ROM), in compliance with all Federal and State coding regulations and reporting requirements. Uses knowledge of coding and compliance guidelines to identify potential documentation, coding and reimbursement issues and report these to coding leadership. Maintains dynamic communication with physician advisors, coders and CDI teams to identify root cause of coding and clinical validation denials and seeks to resolve incongruence with appropriately assigned final DRG by providing feedback and trended data back to key groups. Coordinates denial appeals follow-up. Maintains data and assists with identifying patterns of denial activity. Monitors payer response to appeal activity. Analyzes provider data looking for individual, group, and peer outlier denial trends that could benefit from additional education. Convey support and education as needed to providers focused on improving processes and the quality of their documentation on a case-by-case basis to accurately reflect patient care in the medical record. Maintains denial results through the appeals process as feedback for Coding, Revenue Cycle, Quality, CDI and providers for further education. Creates & provides reports of cases with missing, ambiguous, contradictory, etc. documentation to assist with improvement of physician documentation which supports code assignments and prevents denials. Partners with Managed Care to provide feedback on ways to improve contracts to help prevent against future denials. Interacts with other departments to resolve coding issues. Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards. Collaborates with Coding and CDI to develop and maintain coding curriculum and training materials. Provides feedback, supporting documentation for code changes, and education to the coders, CDI, Quality, and physicians. Assists with medical record documentation to ensure accuracy of coded and other data elements. Participates in on site, remote and/or external training workshops and training. Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS, Specialty areas and Quality; perform other duties as assigned. Identifies trends in coding reviews and makes suggestions for continual process improvement. Performs other duties as assigned.

Requirements

Education - Certification Program, Registered Nurse (RN) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC), Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) or other approved coding credential; Respiratory Therapist, Physical Therapist.
Experience - Four (4) years in patient coding and abstracting with healthcare billing process experience in acute care setting. Experience with denials preferred.
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS) or other approved coding credential.
Ability to pass coding test.
Ability to demonstrate high coding productivity and accuracy
Knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
Ability to apply broad guidelines to specific coding situations, independently utilizing discretion and a significant level of analytic ability.
Understanding denials, writing appeals, and understanding the differences between coding and clinical language.
Knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG, clinical documentation strategies and Medicare, Medicaid, and external regulatory requirements.
Skilled in clinical documentation, auditing, compliance and coding including MS-DRG, APR-DRG, ICD-10, Revenue, CPT and HCPCS codes, and risk adjustment impacts (SOI/ROM, HAC, PSI, Mortality O/E).
Observation, analytical/critical thinking and problem-solving skills.
Communication skills.
Skilled in clinical documentation, auditing, compliance and coding including MS-DRG, APR-DRG, ICD-10, Revenue, CPT and HCPCS codes, and risk adjustment impacts (SOI/ROM, HAC, PSI, Mortality O/E).
Ability to work effectively, independently and manage multiple demands consistently.
Proficient computer skills (spreadsheets, database)

Responsibilities

Formulates and submits letters of appeals for coding and clinical validation denials by providing appropriate clinical documentation, supported by current industry guidelines, medical management standards and protocols.
Adheres to all appeal timelines as prescribed by payer agreements.
Applies ICD and ICD-PCS codes including major traumas, and Neonatal Intensive Care Unit (NICU) records based on review of clinical documentation.
Verifies assignment of DRGs, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures.
Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines.
Codes inpatient records periodically based on review of clinical documentation.
Ensures the validity and accuracy of ICD coding, Diagnosis Related Group (DRG), Severity of Illness (SOI), Risk of Mortality (ROM), in compliance with all Federal and State coding regulations and reporting requirements.
Uses knowledge of coding and compliance guidelines to identify potential documentation, coding and reimbursement issues and report these to coding leadership.
Maintains dynamic communication with physician advisors, coders and CDI teams to identify root cause of coding and clinical validation denials and seeks to resolve incongruence with appropriately assigned final DRG by providing feedback and trended data back to key groups.
Coordinates denial appeals follow-up.
Maintains data and assists with identifying patterns of denial activity.
Monitors payer response to appeal activity.
Analyzes provider data looking for individual, group, and peer outlier denial trends that could benefit from additional education.
Conveys support and education as needed to providers focused on improving processes and the quality of their documentation on a case-by-case basis to accurately reflect patient care in the medical record.
Maintains denial results through the appeals process as feedback for Coding, Revenue Cycle, Quality, CDI and providers for further education.
Creates & provides reports of cases with missing, ambiguous, contradictory, etc. documentation to assist with improvement of physician documentation which supports code assignments and prevents denials.
Partners with Managed Care to provide feedback on ways to improve contracts to help prevent against future denials.
Interacts with other departments to resolve coding issues.
Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.
Collaborates with Coding and CDI to develop and maintain coding curriculum and training materials.
Provides feedback, supporting documentation for code changes, and education to the coders, CDI, Quality, and physicians.
Assists with medical record documentation to ensure accuracy of coded and other data elements.
Participates in on site, remote and/or external training workshops and training.
Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS, Specialty areas and Quality; perform other duties as assigned.
Identifies trends in coding reviews and makes suggestions for continual process improvement.
Performs other duties as assigned.