Claims Coding Specialist

GENERAL RESPONSIBILITIES: Responsible for reviewing medical claims prior to submission and following up on more complex or problem claims or insurance types as designated by the Director. Reviews payer coding policies and procedures to ensure that the department remains in compliance with specific claims submission rules in order to reduce denied claims. Maintains education on coding requirements for ICD-10, CPT, HCPCS, ADA, and FQHC specific coding rules, including revenue and rate codes in addition to category II coding for our value base payment arrangements. SPECIFIC RESPONSIBILITIES: Acts as the primary resource over the medical coding function; reviews the work of other medical coding and clinical staff to ensure compliance with departmental policies and other applicable laws and regulations; identifies and documents patterns of improper coding and suggests solutions. Educates providers and gives feedback to Director of Revenue Cycle Collaborates with practice managers and Director to ensure health center staff receive adequate training and to resolve any identified performance problems. Educates physicians and other health care practitioners to improve accuracy of chart coding; advises them on proper code selection, required documentation, procedures, and other requirements; identifies performance issues and brings them to the attention of the Director of Revenue Cycle. Evaluates medical record and coding to optimize reimbursement, and ensure legal compliance and accuracy in billing and medical documentation for private and government programs; identifies areas that would permit enhanced reimbursement and reduce denials of claims. Verifies correct payment of claims in accordance with contracts, calling payers on open claims, sending appeals on denied claims and following up on requests for information for designated departments and special projects. Maintains strict confidentiality regarding medical records and other PHI. Provides backup as necessary to answer Patent Account telephone calls. Assist with audits by independent auditors, state insurance examiners, and insurance plan representatives. Perform Ad-Hoc audits as needed/requested by Director. Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation; develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery. Assists in training of Patient Account staff as needed and/or requested by the Director. Active participant with IPS and other FQHC partnerships to collaborate coding, billing and value based data. Demonstrates knowledge of Common Procedural Terminology (CPT), International Classification of Diseases (ICD-9 and ICD-10), ADA ( American Dental Association), and Health Care Procedural Coding System (HCPCS) coding; use of modifiers documentation guidelines for medical service provision, patient case management, follow-up, and billing; Local Medical Review Policies (LMRP) for Medicare and Medicaid services; Medical terminology and abbreviations; Medicare and Medicaid programs including medical documentation, covered services, billing regulations, and eligibility of physicians and patients. Ability to research and analyze data, draw conclusions, and resolve issues; read, interpret, and apply policies, procedures, laws, and regulations; read and interpret medical procedures and terminology Work independently, maintain confidentiality, maintain effective working relationships with physicians and other staff, prepare reports and related documents, write in a clear and understandable manner, exercise independent judgment, influence and coordinate the efforts of others over whom one has no direct authority. Demonstrate current competencies in healthcare billing practices and trends applicable to the job, and participate in ongoing professional development required to maintain certifications. Ability to travel to all Whitney Young locations. Demonstrates excellence in both internal and external customer service. Understands and adhere to HIPAA compliance, corporate compliance and client confidentiality. Ensures and/or remains in compliance with local, state, and federal regulation, i.e. DHHS HRSA and NYSDOH, and all accreditation standards (e.g. Joint Commission and NCQA-PCMH). Adheres to the National Patient Safety Goals as defined by the Joint Commission and Whitney M. Young Jr. Health Center. Completes other duties as assigned. Requirements MINIMUM QUALIFICATIONS: High School diploma/GED required. Certification from the AAPC as a Certified Professional Claims Coder required. Four (4) years of progressive experience in medical billing and claims processing in a multi-specialty healthcare setting. Professional coding experience required in WYH specialties. Ability to perform highly complex and varied tasks requiring professional discretion and independent decision making, proficiency with practice management systems, Excel and Word. PREFFERED QUALIFICATIONS: Associates degree. Clinical degree/background preferred. Prior experience reviewing and coding from medical records. Behavioral Health, Mental Health, Substance Abuse, OB/Gyn, Value Based coding experience a plus. Athena, Denticon, 10E11(eCR) experience also a plus. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status. Salary range: $24.50 - 27.50 hourly

Created: 2024-10-19