Program Specialist VI

TX-HHSC-DSHS-DFPS•Austin, TX

2d•$5,417 - $5,875•Hybrid

About The Position

The Program Specialist (PS) VI is selected by and reports to the manager of the medical coders supporting the Hospital Utilization Review (HUR) program within the Office of Inspector General (OIG). The position performs highly advanced (senior-level) consultative services and technical assistance work under minimal supervision, with considerable latitude for initiative and independent judgment. Work includes independently reviewing and updating changes to hospital claims made during the hospital utilization review process by analyzing worksheet documentation to accurately code final diagnoses and procedures using 3M grouper and Optum EncoderPro software; assessing education needs, developing, and providing training; acting as subject matter expert on coding issues; analyzing the impact to coding requirements coming from changes as a result of the legislative process and changes to federal and state regulations; participating in updating, developing, and testing hospital applications; and performing other duties as assigned. The PS VI works closely with program leadership to ensure timeliness and accuracy of assigned tasks.

Requirements

Current certification as Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and/or other certifications related to hospital coding such as Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC) required.
Knowledge of diagnoses and procedures codes.
Knowledge of the 3M Grouper software for accurate diagnoses and procedures codes and assignment of a diagnosis-related group (DRG).
Knowledge of utilization review functions.
Knowledge of Medicare and Medicaid regulations and state and federal laws related to coding.
Skill with assessing education needs, training using appropriate methods, evaluating, and revising training as necessary.
Skill with coordinating and leading as needed to assign and prioritize work of others to meet agency goals and objectives.
Skill in problem solving including analysis, problem identification, planning, and evaluation.
Skill in project management to coordinate the delivery of coding results, education, and diagnosis-related group validation.
Skill in reviewing, revising, and implementing program procedures and policy.
Skill in conducting research of federal and state regulations for compliance and revision of policy and procedure.
Skill in analyzing and interpreting proposed changes in legislation and regulations and providing written responses.
Ability to evaluate program performance and compliance.
Ability to use performance measures and data to make recommendations for improvement.
Ability to develop, prepare reports, and conduct special projects and studies to recommend program changes.
Ability to communicate effectively verbally and in writing.
Ability to utilize computers and applicable software programs including Microsoft Office applications such as Excel and Word.
Ability to work in a team environment.
Ability to work effectively and maintain positive relationships with others.
Ability to provide customer service in a professional manner.
Graduation from an accredited four-year college or university.
A minimum of four years of experience with inpatient hospital coding.
Education and experience can be substituted for one another.

Nice To Haves

Experience using a personal computer and Microsoft Office applications such as Word, Excel, and Outlook is preferred.
Experience with utilization review functions for hospital services is preferred.

Responsibilities

Independently reviews and updates changes to hospital claims due to the utilization review process.
Initiates daily worksheet reviews by analyzing worksheet documentation to code final diagnoses and procedures in compliance with correct coding guidelines and analyzes and researches coding guidelines and federal and state regulations as needed.
Updates the coding changes, deletions, and sequencing in the coding application using the correct version of the 3M Grouper and Optum EncoderPro software.
Communicate verbally and in writing decisions regarding coding changes.
Consults and provides technical assistance to utilization review staff and providers for the correct coding and sequencing of diagnoses and procedures.
Collaborate with management and staff to maintain coding requirements, policies, and procedures.
Monitors compliance with policies and procedures and changes for program impact.
Coordinates with and makes recommendations to management and leadership for policy revisions, procedures, and compliance verbally and in writing.
Performs quality control by sampling completed coding reviews to identify error-prone coding, evaluates accuracy, recommends, and initiates education and procedure changes for improvement.
Assesses education needs, develops, and provides training to staff either ongoing or as requested by management.
Initiates telephone conferences, webinars, or individual training sessions to address learning needs.
Monitor coding questions and issues that require education and program improvement.
Provides written updates to user guides, handbook, and training materials as necessary.
Represents the unit as a subject matter expert for coding issues at meetings or other forums with stakeholders, hospitals, associations, state agencies, claims administrators, contractors, and other units of the OIG.
Make recommendations to management to resolve complaints.
Provides oral and written input at meetings or other forums requiring expertise in coding issues and program procedures.
Acts as a resource for other state agencies and program areas for coding inquiries.
Participates in the legislative process by developing responses to legislative changes or inquiries that impact coding requirements and the utilization review program.
Analyzes proposed legislation for program impact and provides analysis orally or in writing.
Identifies changes in coding interpretations as a result of federal and state regulations.
Analyzes the impact of regulatory changes on the coding process.
Develops recommendations to address program compliance with regulatory changes.
Participates in work groups or meetings with IT or contractors for updates to or development of new versions of the hospital application, including participating in user application testing.
Recommends necessary changes to maintain program compliance.
Works with management to evaluate training materials including handbooks and user guides for hospital applications.
Performs other duties, including special projects, as assigned.
Keeps management and leadership up to date on program as necessary or as required.
As directed, participates in planning of assignments impacting the work of others and may coordinate and lead assigning and prioritizing work of others.