Core Responsibilities and Essential Functions:

DRG Validation, RAC and Government Entity Reviews, Appeals, Overpayment Review Function

sInvestigate overpayment and underpayment issues through DRG reviews, responses to RAC and other governmental audit requests, internally generated audit requests, Epic Work Queue assignments

:* Conduct data sampling, auditing, and reporting on all reviews associated with the Annual IP Coding Assurance Audit plan and as otherwise directed to the level of detail required

;* Participate in Epic Work Queue assignments as necessary to ensure compliance with governmental and internal regulations

;* Research official guidelines to plan scope of focused reviews

;* Participate and lead audits with focus on inpatient hospital ICD9-CM, ICD-10-CM / PCS, some CPT4 coding as well as National and Local Coverage Determinations, OIG Work plan, and any other federal/state regulations

;* Communicate trends and audit findings with the respective hospital departments and educate as appropriate

;* Prepare Findings and Executive Summary reports to distribute to coding and compliance leadershi

p* Prepare and distribute audit findings worksheets to coders

;* Engage in cooperative education with the coders when discussing audit findings

;* Assist in data warehousing, data reporting, and data integrity tasks of audit data housed in Compliance dbs and spreadsheets

;* Direct resubmission of claims and help prepare disclosures as necessary

.Benchmark comparisons and identification of trends and errors in coded dat

a* Review data analytics

;* Identify / track trends and errors to identify overpayments or revenue enhancement opportunities

;* Trend and analyze denials, provide feedback and education to all entities

;* Identify, find solution, communicate solution with both external and internal customers as required utilizing Findings and Executive Summary formats

;* Distribution and analysis of reports to relevant, affected departments

;* Provide and participate in error resolution to correct variances in coding and/or charge practices

;* Assist with the implementation of new processes as needed to assure error resolution

.Provide education and suppor

t* Review CMS regulations and official coding guidance to stay abreast of coding/billing regulatory changes

;* Summarize National/Local Coverage Determinations

;* Presentations (Develop and present coding/compliance education material)

;* Provide denial/appeal follow-up

;* Provide post review follow-up education with WellStar employees, management and physicians

;* Provide education on new releases from Medicare and Medicaid

;* Answer compliance/documentation/coding/billing questions via e-mail

.Performs other duties as assigne

dComplies with all Wellstar Health System policies, standards of work, and code of conduct

.

Required Minimum Educati

• on:
  Bachelor or Associate-level degree in Health Information Management, Business, or other health care related field prefer
• red.An Associate's degree OR a combination of 5 years comparable experience with hospital coding, billing, and reimbursement experience may be substituted for an Associate's deg

ree.
Required Minimum License(s) and Certificatio

n(s):
All certifications are required upon hire unless otherwise s

• tated.Reg Health Information Admin (RHI
• A), orReg Health Information Tech (RHI
• T), orCert Coding Specialist (CC
• S), orCert Professional Coder-Hospital OP, (CPC
• -H) orCertified Coding Specialist – Physician Based (

CCS-P)

Required Minimum Exp

erience:5 years inpatient coding experience and 1-2 years hospital-based outpatient services coding experience r

equired.
Additional one year inpatient audit experience p

referred.

Required Mini

mum Skills:
Excellent communication, organization, and educati

onal skills.Extensive knowledge of medical terminology, ICD-10-CM and ICD-10-PCS coding (as well as ICD-9-CM), CPT-4 procedural coding (including Level II HCPCS), and all coding and billing

guidelines.Hospital billing experience with focus on govern

ment payors.Extensive experience with (electronic) medical record chart review and/or extraction, hospi

tal billing.Extensive experience with Medicare, Medicaid, and reimbursement rules and

regulations.Experience with management information systems and medic

al software.Competence in Microsoft Word and Excel software in a Windows environment (Experience with Microsoft Access

Is a plus).