Medical Billing and Coding

• Completes electronic and manual billing for all patient accounts in a timely manner.
• Performs electronic billing via electronic health record and clearinghouses.
• Demonstrates knowledge of HCFA 1500 billing criteria.
• Demonstrates comprehensive ability and knowledge of electronic claims processing, electronic remittance advice, electronic payment posting, and clearinghouse functions.
• Demonstrates knowledge of CPT-4, ICD-10, usage of modifiers, and HCPCs coding according to all federal and state regulatory guidelines.
• Demonstrates a thorough knowledge and understanding of benefits and/or coverage as indicated by third party payer requirements.
• Demonstrates in depth knowledge of insurance authorizations with relation to medical billing.
• Performs and regularly updates insurance and physician credentialing to ensure timely processing and payment of claims.
• Communicate with work partners to inform of instructions necessary to complete tasks in a timely fashion.
• Promptly corrects and processes rejected, invalid or denied claims.
• Effectively manages accounts receivable and collections for all assigned clients.

Medical Billing Specialist

• Reviewing documentation and selecting the appropriate procedure and/or diagnosis code to be entered in billing documents
• Ensuring that teaching physician requirements are met and are clearly reflected in the documentation
• Other duties as assigned

Certified Coder – Practice Operations, Certified Professional Coder

• Codes and abstracts professional fee hospital services from medical records according to guidelines
• Utilizes 3M Encoder for validation of RVUs and procedure unbundling
• Maintains a 95% coding accuracy rate

Emergency Department Medical Coder – Per Diem

• Reviews and interprets medical information, physician treatment plans, course, and outcome to determine appropriate ICD-10 CM/CPT codes for diagnoses and procedures. ( 65%)
• Abstracts data elements to satisfy statistical requests by the hospital, health system, medical staff, etc. and enters all coded/abstracted information into designated system. ( 15%)
• Ensures efficient management of medical information and cash flow as it pertains to the unbilled coding report. ( 10%)
• Keeps informed of the changes/updates in ICD-10 CM/CPT guidelines by attending appropriate training, reviewing coding clinics and other resources and implementing these updates in daily work. ( 5%)
• Performs other duties as assigned or required. (5%)

Coder – Outpatient

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – Cardiology

• Code claims directly from the medical record/operative report according to coding guidelines.
• Accurate and timely completion of work queues as assigned.
• Track and identify trends within charge review and follow up work queues and assist leadership in the resolution of those trends and/or educational needs.
• Assists with research of denied claims.
• Maintains compliance with established corporate and departmental policies and procedures, quality improvement program, customer service and productivity expectations.
• Must be able to achieve individual quality and productivity performance metrics in daily duties as set by coding leadership.
• Provide and/or assist with provider education, as well as the development of educational tools.
• Communicates professionally with physicians, management, and peers.
• Participates in all educational activities including coding meetings/calls necessary to provide information relating to coding and compliance.
• Remains abreast of changes to current payer guidelines, Correct Coding Initiative edits, and Local/National Coverage Determinations for accuracy in Coding and mentors team members regarding coding guidelines and accuracy.
• Assists with training of other coders.
• Takes initiative for learning new skills and willingness to participate and share expertise on projects, committees and other activities as deemed appropriate.
• Demonstrates personal responsibility for job performance.
• Extensive knowledge/experience in physician coding with expert knowledge in a specific coding specialty and the ability to provide education/support to coding team and providers.

Specialized Coder – Cardiology, Vascular, CVTS

• Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations.
• Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement.
• Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
• Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
• Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required.
• Using the Encoder software program, determines the codes for all diagnoses and procedures.
• Queries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
• Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc. documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.

Medical Coder

• Codes and abstracts diagnosis and procedure information from patient medical records according to AHA ICD-10-CM/PCS coding conventions, UHDDS and CMS guidelines and regulations
• Utilizes the 3M Encoder to verify and assign AHA ICD-10-CM/PCS codes, and MS-DRG/APR-DRG assignment
• Maintains 95% data quality coding accuracy rate as measured through quarterly department quality reviews
• Maintains daily productivity and turnaround times
• Responsible for remaining up-to-date with knowledge of AHA ICD-9-CM/ICD-10-CM/PCS coding conventions, MS-DRG and APR-DRG principles and guidelines
• Maintains a working knowledge of prospective payment systems as it relates directly to coding process
• Participation in department and sectional meetings, education sessional sessions and workshops as scheduled
• Maintains working knowledge of clinical documentation improvement program and functions as liaison for RN clinical documentation specialists
• Demonstrates/models the Network’s core values and customer service behaviors in interactions with all customers (internal and external)
• Maintains confidentiality of all materials handled within the Network/Entity as well as the proper release of information.

Inpatient Coding Specialist – Full Time

• Reviews the content of medical records for hospital and professional inpatient or outpatient records
• Identifies principal diagnosis, secondary diagnoses and procedures performed
• Translates diagnostic and procedural phrases utilized by healthcare providers into coded form
• Using Encoder software, determines the codes for all diagnoses and procedures
• Assigns the appropriate DRG and codes based on hospital and professional coding guidelines

Medical Coder – DRG Inpatient

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – ENT, Audiology

Certified Coder – Practice Operations – Part-Time

• Deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs through HCC coding, medical coding, clinical terminology and anatomy/physiology
• Conduct quality assurance (QA) review of internal coding team members
• Provide coding education to team
• Evaluate HCC coding questions and independently renders guidance on appropriate coding determinations
• Supports RADV audits
• Specializes in performing second level review of HCC validation
• Prepares documentation and coversheets for upload to regulatory body and/or independent auditor
• Analyzes results
• Develop presentations to improve provider documentation and accuracy
• Conducts Quality Assurance (QA) reviews on internal coders
• Guides coding decision making adhering to CMS Guidelines for Coding and Highmark’s Policy and Procedures

Lead HCC Coding Specialist

Coder – Outpatient, Part-Time

• Ensure timely and accurate billing for outstanding claims
• Demonstrate excellent customer service to patients, healthcare professionals and insurance carriers
• Work in a fast paced and team focused environment to ensure timely and accurate billing to insurance providers
• Resolve insurance problems and patient issues that may have resulted from incorrect or incomplete information, therapy changes and pharmacy or shipping errors
• Maintain patient demographic and insurance information and data collections systems
• Research and respond to insurance companies regarding billing issues or related questions

Medical Billing Coordinator – Revenue Cycle

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties.
• Meets minimum requirements for production and quality monthly.
• Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component.
• Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses.
• Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs.
• Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, or un-substantiated care rendered.
• Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters.
• Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF).

Inpatient Coder

• Responsible for assisting the coding department with the day-to-day non-coding duties support activities
• Assigns codes to office-based visits and procedures using the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• Resolve coding edits to assure accurate and complete claims submission
• Sequences diagnoses and procedure codes as outlined in CPT, ICD-10-CM, and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines
• Reviews all clinician documentation to support assigned codes in the health information record
• Follows up and obtains clarification of inaccurate documentation as appropriate
• Codes risk adjustable encounters, resolves CRMs, and trends coding denials, as assigned
• Conducts formal coding and documentation reviews, clinician reviews and quality reviews, as assigned
• Assists with coding research functions and education activities
• Creates clinician coding and documentation education based on query trends or ad-hoc requests
• Adheres to the organization and departmental guidelines, policies, and protocols.
• Abides by Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement
• Maintains confidentiality of patient.

Physician Support Coder

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties.
• Meets minimum requirements for production and quality monthly.
• Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component.
• Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses.
• Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs.
• Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, or un-substantiated care rendered. (i.e., varying modifier assignment for EAPG vs. Non-EAPG payer specificity)
• Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters.
• Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF).
• Demonstrates an excellent working knowledge of hospital information systems to retrieve data specific information (i.e., order diagnosis, patient type) within a complicated filing schema including non-hospital data (i.e., Media Tab, Office Visits etc)

Facility ED Coder

• Evaluate medical records and provide clinical and surgical abstraction
• Accurately code diagnostic and procedural information
• Consult with medical providers for record clarification
• Ensure compliance with coding rules and regulations
• Compile reports and tabulate data from medical records
• Identify validation edits and ensure accurate coding
• Work independently under regular supervision

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