Franciscan Health

Claims Specialist

• Performs duties related to the timely and accurate adjudication of PACE participant medical claims while maintaining advanced knowledge of coding and billing rules.
• This includes data entry, processing manual and electronic claims, verifying authorizations, issuing claim payments and remittance advice, and processing claim denials.
• Responsible for working complex or high-priority claims, ensuring accuracy and compliance.
• Reviews escalated claim issues and delivers resolutions in alignment with CMS requirements.
• Ensures claims adhere to CMS rules, Medicare guidelines, and PACE-specific policies.
• Collaborates with the interdisciplinary team (IDT) to resolve discrepancies in authorizations or documentation.
• Conducts any necessary follow up with internal and external stakeholders.
• Supports the PACE Claims Specialist I in providing industry leading customer service to PACE vendors.
• Builds and modifies vendor profiles as program’s vendor network changes.
• Verifies updates to Medicare and Medicaid rates and codes are accurately reflected in claim adjudication software.
• Performs monthly EDPS reporting and error clearance.
• Generates detailed claim performance reports, identifying trends and potential areas for improvement.
• Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software.

Claims Specialist II – PACE

Medical writer

• Develop and maintain all CDI education, training policies and procedures, and CDI reference materials.
• Lead training sessions and assess CDI comprehension of covered materials.
• Make recommendations for the development of CDI resources and policy and procedure development.
• Develop and maintain a consistent CDI operations orientation program and report the CDS’s progress to CDI leadership throughout the orientation and training process.
• Serves as the subject matter expert with regards to medical terminology, anatomy/physiology, reimbursement schemes, public reporting of outcomes, quality of patient care outcome measures, and the interpretation of coded data as it relates to revenue cycle compliance.

Clinical Documentation Integrity Education Specialist

Medical Billing and Coding

• Accurately review and code patient records in the following clinical areas: hospital acute inpatient services.
• Meet defined coding accuracy and production standards and demonstrate a thorough knowledge of coding guidelines, medical terminology, anatomy/physiology, reimbursement schemes, and Payor specific guidelines.
• Review and analyze the content of medical records to appropriately assign ICD diagnosis procedure codes, CPT procedure codes, and modifiers to meet coding guidelines.
• Notify coding leadership of trends and topics for education and feedback to physicians and departments.
• Identify and enter data elements for abstracting.
• Participate actively in performance improvement teams, projects, and committees.
• Serve as a Superuser and assist with system testing.
• Serve as a backup to coding reimbursement specialist.

Hospital Inpatient Coder VI

Manager

• The Corporate Coding Manager develops and implements coding strategies and provides operational leadership to manage and maintain efficient coding processes.
• Provides oversight and leadership to the Coding Supervisors within the department, and manages the performance of coworkers through ongoing coaching, feedback, and development to motivate, engage and drive a high performing team.
• Oversees the auditing and education program to ensure accurate and compliant coding and billing practices.
• Makes decisions regarding changes to coding staff day-to-day functions; aligns all aspects of coding operations to align acute and ambulatory corporate initiatives, including standardized corporate coding policy and procedure development and enforcement.
• Participates in problem identification, performs root cause analysis, and develops a solution that produces expected outcomes and intended results.
• Assists with the development of the organizational wide standardization and implementation of a corporate coding compliance plan to include compliance with external regulatory and accreditation requirements.
• Creates an environment that coworkers want to work in and maintain a high level of coworker satisfaction.
• Serves as department liaison for regional meetings and projects and to other teams that interact with the coding team; assists with items specific to coding needs for planning of new department builds and department revisions.
• Acts as a nosologist, analyzing and interpreting disease and procedure classifications and terminologies for the accurate translation of healthcare data; applies broad guidelines to specific coding situations, independently utilizing discretion and a significant level of analytic ability.
• Maintains expert knowledge of Franciscan Alliance coding software tools; assists with development and maintenance of software system workflow for standardization and maximum efficiency.
• Assists with identification and implementation of process improvements, according to industry best practice standards, to make the best use of resources, decrease costs and improve coding services across the specialized service lines.

Coding Manager

• Analyzes the ICD 10 codes, suggested by coding software
• Collaborates with Clinical Documentation Specialist to ensure accurate DRG assignment
• Reviews clinical documentation to validate accurate representation of the patient's clinical picture
• Audits accuracy of CAC software autosuggested codes
• Identifies when documentation relevant to coding is missing or inconsistent

Coder VI Specialist – Hospital Inpatient

Therapist

• Performs comprehensive occupational therapy evaluations, treatment and related follow-up services including discharge planning.
• Documents patient assessments and pertinent information in a timely manner.
• Develops a treatment plan with measurable goals based on patient assessment.
• Completes appropriate goal re-assessment and discharge planning.
• Provides occupational therapy, including selection and use of adaptive equipment.
• Collaborates with patient and other healthcare personnel or outside agencies regarding coordination of care.
• Trains and educate patients and family members or others support and document understanding of treatment plan and goals.
• Provides occupational therapy according to standards of care defined by the state practice act and other professional and governing agencies.
• Supervises Occupational Therapist Assistants and Home Health Aides.

Claims Specialist II – PACE

Clinical Documentation Integrity Education Specialist

Hospital Inpatient Coder VI

Coding Manager

Coder VI Specialist – Hospital Inpatient

Home Health Occupational Therapist