Sr Claims Reimbursement and Coding Specialist

CHPW•Seattle, WA

About The Position

This position conducts special and complex claim audits on all claim coding and clinical documentation investigations related to state and federal regulatory and compliance requirements, identifying issues and/or entities that may pose a risk for fraud, waste, and abuse. Identified issues and trends result in recommendations for claims process and documentation improvement and education. AAPC and/or AHIMA coding credentials are required. To be successful in this role, you: Have a minimum of 5+ years medical coding/auditing experience, including minimum of 1 or more years in fraud, waste and abuse experience, or any combination of education and experience which would provide an equivalent background. Have a coding certification such as a CPC, and/or CCS required. Additional AHIMA and AAPC certifications considered. Have expert knowledge of ICD-10 and CPT, HCPC and CDT. Are self-motivated, analytical, detail oriented and enjoy working alone or in a team environment Essential functions and Roles and Responsibilities: Examines and analyzes claims data and audits clinical documentation both prepay and post pay of providers and entities to ensure compliance with regulatory authorities (CMS, HCA and OIG) and detect and identify opportunities for fraud, waste and abuse prevention and control. Interpret changes in the external regulatory environment and modify CHPW policies accordingly. Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting to aid in identifying aberrant billing issues and trends. Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends, and changes in laws/regulations. Collaborates and participates with regulatory authorities (HCA, CMS and OIG) as needed when related to Program Integrity audit activities. Design and implement process for continual review of coding documentation related to the identification of potential fraud, waste and abuse. Responds to all coding related inquiries from internal and external partners and is the subject matter expert on coding and code sets for the organization. Prepares and provides direct education to external provider partners regarding significant audit findings verbally and through written correspondence, Provider Bulletins, newsletters, and webinars as needed. Identifies and recommends possible interventions for improper payments and risk avoidance based on the outcome of the investigation, and/or proactive review of data. Collaborates with Compliance and other internal areas on matters of mutual concern to determine patterns of billing behavior. Reviews coding and supporting documentation and has the authority to make decisions and determinations for claim recoupment and first and second level appeals. Identifies and supports system configuration activities including coding editing system and benefits. Identifies and develops training materials for healthcare providers and trains new associates. Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Requirements

AAPC and/or AHIMA coding credentials are required.
Have a minimum of 5+ years medical coding/auditing experience, including minimum of 1 or more years in fraud, waste and abuse experience, or any combination of education and experience which would provide an equivalent background.
Have a coding certification such as a CPC, and/or CCS required.
Have expert knowledge of ICD-10 and CPT, HCPC and CDT.
Are self-motivated, analytical, detail oriented and enjoy working alone or in a team environment
Ability to review large data sets from an analytical perspective to aid in identifying potential fraud, waste and abuse.
Ability to manage multiple cases of varying size and complexity.
Knowledge of Medicare and Medicaid guidelines, including the CMS 1450, 1500 and ADA dental claim forms used for billing.
Knowledge of WACs and RCWs related to healthcare.
Advanced, applied knowledge of CPT, HCPC, CDT and ICD-CM codes, coding conventions and coding guidelines.
Proficiency with computer business applications, and a working knowledge of electronic medical record (EMR) software.
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines
Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data
Time management and organization skills with the ability to manage and prioritize work to meet deadlines.
Written and verbal communication skills; able to communicate with and collaborate effectively with physicians, CHC partners and Affiliates.
Written and verbal communication skills for effective communication with all internal and external partners.
Skilled in Microsoft Office programs including Word, Excel, and
Complete and successfully pass a criminal background check.
Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

Nice To Haves

Additional AHIMA and AAPC certifications considered.

Responsibilities

Examines and analyzes claims data and audits clinical documentation both prepay and post pay of providers and entities to ensure compliance with regulatory authorities (CMS, HCA and OIG) and detect and identify opportunities for fraud, waste and abuse prevention and control.
Interpret changes in the external regulatory environment and modify CHPW policies accordingly.
Keep current on regulatory and coding issues/best practices including AHA Coding Clinics and ICD-10 Official Guidelines for Coding and Reporting to aid in identifying aberrant billing issues and trends.
Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends, and changes in laws/regulations.
Collaborates and participates with regulatory authorities (HCA, CMS and OIG) as needed when related to Program Integrity audit activities.
Design and implement process for continual review of coding documentation related to the identification of potential fraud, waste and abuse.
Responds to all coding related inquiries from internal and external partners and is the subject matter expert on coding and code sets for the organization.
Prepares and provides direct education to external provider partners regarding significant audit findings verbally and through written correspondence, Provider Bulletins, newsletters, and webinars as needed.
Identifies and recommends possible interventions for improper payments and risk avoidance based on the outcome of the investigation, and/or proactive review of data.
Collaborates with Compliance and other internal areas on matters of mutual concern to determine patterns of billing behavior.
Reviews coding and supporting documentation and has the authority to make decisions and determinations for claim recoupment and first and second level appeals.
Identifies and supports system configuration activities including coding editing system and benefits.
Identifies and develops training materials for healthcare providers and trains new associates.
Other duties as assigned.