***Not a remote position*** Clinical Experience a MUST**
Summary:
The role of the Clinical Coding/Documentation Improvement Specialist (Quality Improvement/Medicare Risk Adjustment – QI/MRA/UM/Care Coordinator) is to monitor and audit medical record documentation, coding and quality measures, utilization and billing in the Practice offices. It is crucial for the Clinical Coding/Documentation Improvement Specialist (Quality Improvement/Medicare Risk Adjustment – QI/MRA/UM/Care Coordinator) to have knowledge of 5 STAR, PQRS, HEDIS, CMS coding and billing guidelines, clinical standards, practice guidelines, utilization management knowledge and outcomes management skills.
The personnel in this position uses their knowledge of ICD-9/ICD-10, CPT, and documentation guidelines, along with clinical skills and practice management knowledge to assist in any and all coding and documentation audits and/or billing functions as determined by the Compliance, Operations, and/or Quality department(s) while ensuring that all quality measures are completed annually for the patient populations for both Managed Care and Medicare. Additionally, they must be able to perform analytics on the Practice expenditures for clinical care and manage the utilization in the Practice appropriately.
Skills:
Communication / Coordinate sharing of pertaining information accurately
Critical Thinking / Problem solving/Computer / EHR system
Clinical background
Practice Management skills
Understanding of appropriate Practice Clinical guidelines and practices
Ability to travel
Ability to read and analyze medical records
Ability to perform Clinical Correlations
Proficiency with ICD -10 , CPT codes and QIP measures – CPC or CSSP is necessary
Understand coding and billing guidelines.
Understand and utilize the principles of care management
Duties and Responsibilities: Include but are not limited to:
Performs all audits of documentation, coding and billing practices in whatever office or capacity it is required.
Follows most recent documentation and coding guidelines
Uses only pre-approved source documents as validation for recommendations
Queries providers on specificity of coding whenever there is any question and clarifies all
Creates and assists with the maintenance of Chronic Condition Lists for all PCPs
Assists with working the missing condition reports from all carriers
Assists with all quality measures initiatives – working with the PCP offices in capturing the data to support the variables.
Assists with the analysis and action planning in response to findings of the utilization practices in the office
Assists in the care coordination duties as necessary in specific patient populations and works with Case Management to procure services for those identified patients
Assists in teaching any office staff and/or providers in proper documentation and coding guidelines as necessary
Reports any issues to Quality, Compliance and Operations as necessary.
Is responsive to anyone who has questions regarding this area of expertise.
Performs all other coding and documentation reviews and/or projects as asked and assists/coordinates strategies as defined by the department head or assistant.
Education and Experience:
Prefer candidate to have some clinical background and current ICD-10 coding certification or equivalent. 1-2 years of coding experience in any medical field and/or must demonstrate the ability to code proficiently by passing a coding test at interview. Experience with the MRA reimbursement structure is required.
Must become certified with a minimum of a CPC within 1 year of hire.
Language Ability:
Ability to read and comprehend instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one situations to providers, office staff, insurance companies, and other employees.
Computer Skills:
To perform this job successfully, an individual should have knowledge of Microsoft Word, Excel, Internet software, Email software, and insurance web sites.
Work Environment:
The noise level of the work environment is usually moderate.
Physical Demands:
The employee must have close vision ability. While performing the duties of this job the employee is regularly required to sit, use hands and arms, talk and hear.
Job Type: Full-time
Pay: $16.00 - $18.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Experience:
- quality coordinator: 1 year (Preferred)
- Pharmacy technician: 1 year (Preferred)
- part B: 1 year (Preferred)
- pharmacy: 1 year (Preferred)
- HEDIS: 1 year (Preferred)
- LPN: 1 year (Preferred)
License/Certification:
- LPN (Preferred)
- Medical Assistant (Preferred)
Work Location: In person
