Billing Analyst, Lab Outreach
Wellstar Health System
Unity
Job Level
Mid-LevelSenior
Tech Stack
Unity
About the role
- Validate the accuracy of ICD-10-CM, ICD-10-PCS, and DRG and APR group appropriateness, CPT and HCPCS inpatient patient and outpatient facility claims
- Audit inpatient claims to identify DRG codes that may have been over-assigned, ensuring accurate reimbursement aligned with regulatory and contractual guidelines
- Identify and resolve complex coding discrepancies
- Write technical rationales for correct documentation and code changes
- Communicate complex coding findings to project lead and other cross functional teams (clinicians, engineers, product managers)
- Apply state-of-the-art machine learning software to improve the data quality and medical coding practices of providers and inform next-generation auditing software
- Be responsible and accountable for maintaining confidentiality, integrity, and availability of protected health information; follow HIPAA security policies and report suspected or actual violations or breaches
- Adhere to project deadlines and variable expected work volumes depending upon projects
Requirements
- Extensive knowledge of healthcare industry and experience in and around coding, billing, auditing, compliance and reimbursement for Inpatient and Outpatient facility
- Must have extensive pediatric inpatient facility experience
- 5 years of auditing facility inpatient and outpatient services with DRG and APR-DRG as well as familiarity with clinical documentation improvement practices
- Extensive knowledge of current Official Coding Guidelines and Coding Clinic citations
- Strong background in cost reduction strategies by ensuring correct claims payment and appropriate diagnosis-related group (DRG) assignment including familiarity with inpatient denial coding systems (e.g. CARC codes)
- Proficiency in coding software, electronic health record systems, and familiarity with how AI tools can assist in identifying over/under-assigned DRGs
- Experience in working with technical teams building coding and large language models
- High level proficiency in anatomy, physiology, disease process, and pharmacology
- Detail oriented and deadline driven attitude; ability to think critically and determine the best method for resolving challenges
- Strong organizational skills, a strong sense of accountability, and a proactive work ethic
- Certification Requirements: RHIA, RHIT, or CCS from AHIMA and/or CPMA, CIC, COC from AAPC
- Must follow HIPAA security policies and procedures and maintain confidentiality, integrity, and availability of protected health information
- Ability to work at least 20 to 40 hours a week (contractor capacity)
