Your Role
The Facility Compliance Review (FCR) team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Clinical Coding Analyst RN, Consultant will report to the Senior Manager, Facility Compliance Review. In this role you will be supporting the FCR team in addition to a small clinical coder team of 2 clinical coders who will be responsible for performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes as well as EDC (Emergency Department Coding), MS-DRG and APR-DRG reviews based on clinical determination. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for reviewing outpatient coding for appropriateness of billing related to injection and infusions. This person will review medical records and perform coding analysis on all diagnoses, procedures, DRG/APC and charge codes. Ensure that the billed coding is appropriate based on reimbursement requirements, research, epidemiology, financial and strategic planning and evaluation of quality of care. In this role you will be working in a Lead capacity assisting with reviewing claims, training new hires, facilitating refresher trainings for the team as needed, and being a resource for the team to ask questions. The ideal candidate will have previous leadership experience and hold at least a CPC or CCS certification from AHIMA or AAPC, and higher-level certifications are highly desirable.
We are a CA based company and training hours for the first few months will be 8am-5pm PST. After that, this person can work 6am-3pm, 7am-4pm or 8am-5pm PST.
Your Work
In this role, you will
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
- Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
- Lead duties for small clinical coder team including managing day to day activities of the team, motivating the team to achieve the organizational goals, monthly auditing, attending team huddles and training when needed
- Performs clinical review of post service inpatient, outpatient and ER claims for appropriateness of coding
- Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
- Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
- Clinical judgment and detailed knowledge of benefit plans used to complete review decisions
- Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.
- Willingness to learn multiple EMR systems to retrieve medical records as needed
- Leverages national data and remains current with payer trends needed to educate and lead team to achieve benchmark performance
- Acts as a resource and helps to validate post claim DRG downgrade denials related to coding and clinical determination to support appeal strategy, tracking by disease, payer and denial activity and works with teams to create transparency and improvements to mitigate and prevent denials
- This person will have clear communication, be collaborative, while working effectively and efficiently
- Represent team at cross-functional meetings and be a point of contact for escalations.
- Strong understanding and proficiency of reimbursement methodology, federal, state and payor coding documentation and billing requirements
- Other job duties as assigned
Your Knowledge and Experience
- Associate's degree in nursing is required
- Current unrestricted California RN License and/or in assigned states. If assigned an additional state, they must obtain the CA RN license (in addition to primary assigned state license) within 90 days of hire
- 7 years of prior relevant experience required
- 3 years' inpatient coding experience required
- One of the following is required: Certified Coding Specialist (CCS), Certified Professional Coder (CPC-CIC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Documentation Integrity Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP)
- Utilization management (UM) experience is required
- Ability to analyze claim data analytics is required
- Health plan experience (managed care) preferred
- Strong attention to detail
- Arbitration experience preferred
- Requires independent motivation, solid work ethic, and strong computer navigation skills
- Familiarity with electronic health record (EHR) systems, Oracle (Cerner) and Emergency Department EM leveling experience preferred
- Strong attention to detail
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.