Description

Position Purpose: The focus of this position is to establish processes to respond to ICD-10 coding changes and its effect on inpatient claims payment. Chart review will include DRG pre-payment review, hospital readmission review and outlier payment review.

Conduct MS-DRG and/or APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification

Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing

Expert knowledge of and the ability to:

Must be fluent in the application of current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations, in addition to demonstrating working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments

Solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment

Writes clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics

Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements

Maintain and manages daily case review assignments, with a high emphasis on quality

Will be working in a high-volume production environment that is matrix drive

Education: RN; One year of Nursing experience in managed care organization or acute care hospital; Other RN experience could be considered.

License/Certification: CCS AHIMA Certification/CIC AAPC Certification  CDI/ RHIA/RHIT accepted.  Other Certification will be considered.