PURPOSE OF THIS POSITION

The primary purpose of the Professional Coding Integrity Specialist (PCIS) is to review, enter and/or modify charges as appropriate, including review of clinical documentation to ensure charge is supported and/or to determine specific charge/modifier assignments, for designated clinical areas. 

JOB DUTIES/RESPONSIBILITIES

Duty 1: Review, enter and/or modify charge on encounters to ensure accurate and compliant and optimal charge capture in a time-sensitive manner for designated clinical service lines. Review clinical documentation to ensure charge is appropriately supported and/or to determine the assignment of the accurate charge, modifier, E&M levels, etc.  Assign ICD-10 diagnosis codes as appropriate. Work “exception” accounts (e.g. canceled accounts, combined, unique modifier or charge rules requiring review, etc.) through review of clinical documentation and/or collaboration with appropriate resources, as needed, to resolve.

Duty 2:  Support resolution of claim-scrubber edits (Quadax) resulting from charges entered by the Revenue Integrity Validation team; collaborate with clinical areas, coding, PFS, etc. to support resolution of edits; trend, identify opportunities, and collaborate with RI Educator and/or Claims Resolution Specialist to avoid/reduce future edits.  Support Condition 44 notifications (inpatient to observation status) process by properly modifying charges and calculating hours etc.

Duty 3: Track and quantify revenue impact to organization as a result of charge corrections made, including impacts from modifications to processes.  

Duty 4: Identify opportunities related to clinical documentation and/or other system enhancements to support optimal and accurate charge processes; collaborate with CDI Specialist, Claims Resolution Specialist, Revenue Integrity Auditor, Revenue Integrity Educator, clinical area, and other areas to support resolution of issues.

Duty 5.  Demonstrate proficient knowledge of federal, state and third party charging guidelines of clinical areas supported by the Revenue Integrity Validation team to ensure optimal, accurate and compliant charging. Understand changes to applicable coding and billing regulations, including annual IPPS/OPPS revisions, by resourcing credible references (i.e. CMS website, Craneware, publications, professional contacts, reliable internet sources, seminars, etc.). Collaborate with clinical areas, Revenue Integrity Team, Coding Integrity Team and/or other impacted areas to support implementation of changes.

Duty 6:  Participates in system testing as a result of upgrades, changes, enhancements, new application implementations, etc. that may impact Revenue Integrity Validation processes.  

Duty 7: Regularly attends and actively participates in in-services, organizational and department meetings and continuing education programs as offered in order to remain current with organizational and industry changes and best practice. Communicate and disseminate information to other departments as applicable.

REQUIRED QUALIFICATIONS

An Associate’s degree in a related field including, but not limited to, health information, business or related clinical profession preferred or 1-2 years’ experience from which comparable knowledge and abilities have been acquired. Coding certification (CCA or CPC) required or obtained with 9 months of hire date Knowledge of medical terminology and anatomy and physiology required. Knowledge of CPT/HCPCS/APC coding systems, appropriate use of applying modifiers, CPT Assistant, LCD/NCD and ICD-10 required.   Ability to research, review and interpret Federal, State and Local billing regulations required. Familiarity with utilization of computers and commonly used applications, including Microsoft Office Suite, (Windows, Excel, Word, Outlook), electronic health record, internet required. Ability to track and monitor data to identify trends pertaining to charge issues. Excellent organizational, time management and problem-solving skills required; detail oriented and follow through. Positive service-oriented interpersonal and communication (written and verbal) skills required.

PREFERRED QUALIFICATIONS

Other certifications applicable to primary clinical service line supported preferred. Knowledge of regulatory compliance and reimbursement methodologies preferred. Encoder experience preferred Training and education skills preferred.        

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.

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