Reviews and Resolves coding and charging issues preventing posting of revenue and release of claims. Coordinates changes in charge capture workflows and communicates changes to organization. Works with Epic ancillary teams as well as clinical teams to establish consistent charge flow throughout the medical center. Uses comparative reporting to monitor revenue and usage departmentally. Is responsible for resolving coding/billing edits in the EPIC work queues in a timely manner. Participates in quality assessment and continuous quality improvement activities. Complies with all appropriate safety and infection control standards. Performs all job duties and responsibilities in a courteous and customer-focused manner according to the Hurley Family Standards of Behavior.

Responsibilities

Reviews Visit Coding of HCPCs, ICD, and CPT codes to ensure coding compliance. Completes appropriate documentation for additions, deletions, or changes in accordance with coding/billing criteria as described in third party payer regulations. Coordinates changes with appropriate Information Technology staff.

Audits charges on accounts in which a third party payer/patient has requested charge justification. Compares resources used, clinical documentation, and charges to ensure they are reasonable and customary as well as supported in the legal medical record.

Performs timely review of account for missing charge identification and resolution. Posts charges to accounts and communicates with clinical teams to prevent missing charges from occurring. Reviews charges to ensure routing to appropriate cost center.

Monitors and provides feedback regarding charge lag resulting in late charge processing. Compares revenue and usage departmentally and identifies fluctuations - provides detailed reports and workable solutions.

Resolves coding related claim edits (LCD, NCD, CCI, etc…) and charge review edits and provides feedback regarding charge enhancement and/or diagnosis preference in order to ensure accurate and compliant coding that is consistent with documentation.

Performs combined account resolution for consecutive accounts. Includes review of medical record to determine related clinical documentation between accounts.

Evaluates correct usage of coding modifiers in regards to procedure status indicators as well as consistent application by billing team and communicates necessary changes. Audits billing and coding practices to ensure compliance and provides statistical feedback as well as potential reimbursement effects based on third party payer regulations. Prepares detailed reports of findings and analyzes effectiveness of existing systems/processes and makes recommendations for necessary revisions.

Reviews benchmarking data related to clinic visit charging and validates that the level of care correlates to resources utilized. Communicates with Revenue Cycle Management as well as clinic administrators as requested by supervision.

Reviews and analyzes patient billings, third-party bulletins, manuals, and newsletters to ensure correct revenue codes, procedures, and/or amounts of reimbursement for chargeable service.

Serves as a liaison between physician and facility billing relative to technical and professional billing issues.

Attends pertinent educational seminars and/or meetings to stay current in billing criteria, coding, and reimbursement.

Serves as a liaison between departments in resolving problems related to charges. Works with Charge Master Analyst to develop corrective action plan based on findings.

Receives, maintains, distributes, and communicates all third-party payer bulletins, memos, and advisories relating to billing/reimbursement.

Accesses appropriate computer/information systems for input and retrieval of information.

Qualifications

Bachelor's degree in Accounting, Business, or related field.

Two (2) years of health care experience with third-party payer reimbursement activities, or supervisory experience of staff assigned to facility billing in a hospital/medical center setting, or supervisory experience of staff responsible for charge master accounts.

-OR-

Associate's degree in Accounting, Business, or related field.

Four (4) years of health care experience with third-party payer reimbursement activities, or supervisory experience of staff assigned to facility billing in a hospital/medical center setting, or supervisory experience of staff responsible for charge master accounts or equivalent combination of education and experience.

-AND-

Working knowledge of medical terminology.

Working knowledge of current HCPCS, CPT-4, ICD-9 and/or ICD-10 principles, terminology, and methodology.

Current knowledge of third-party payer requirements and associated regulatory standards including consecutive account requirements.

Knowledge of reimbursement methodologies (emphasis on APC and DRG).

Thorough understanding of current and proposed federal healthcare (Medicare/Medicaid).

Knowledge of basic accounting principles, procedures, and techniques.

Knowledge of third-party payer and government fraud/abuse regulations related to billing/reimbursement.

Demonstrated ability to use computer systems, report writers and applications.

Proficient in Microsoft Office (Excel, Word, Power Point, Outlook).

Ability to create detailed Excel spreadsheets and prepares accurate and detailed technical reports.

Ability to organize and prioritize work to meet timely deadlines.

Ability to work independently and make decisions in accordance with established policies and procedures.

Ability to participate in work groups, task forces, committees, and project teams as a liaison with other analysts, administrators, and revenue cycle management.

Knowledge of electronic and UB-04 and CMS-1500 computerized billing systems and procedures for Hospital and Professional Billing.

Ability to communicate effectively in oral and written form.

Ability to compile, analyze, and evaluate data and to create accurate detailed reports from such data.

Ability to conform to departmental performance standards.

Ability to establish and maintain effective working relations with superiors, co-workers, other Medical Center employees, patients, third party payers, external agency representatives, and the general public.

NECESSARY SPECIAL QUALIFICATIONS: Certification or Registration from the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) must be obtained within 6 months in any of the following areas: Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P),Registered Health Information Administration (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder-Hospital (CPC-H), Certified Professional Coder (CPC).