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

• Accurately enter ABS data (e.g. Surgeon name, procedure date, discharge disposition, admit diagnosis, POA status, etc.) 95% + Accuracy
• Meets or exceeds bill drop dates/AR expectations
• Consistently monitors and manages AR to facilitate dropping of pending, old, or problematic accounts of assigned locations in accordance with 30-Day Bill Drop policy.
• Accurately reports principal diagnosis in keeping with the most current AHA Coding Clinic and ICD-10-CM/ICD-10CM guidelines. 95% + Accuracy
• Manages NCCI and OPPS edits in compliance with industry regulations. Appends modifiers to charges when appropriate.
• Identifies and reports to supervisor recurring charge issues that can be addressed with ancillary department managers.
• Generates appropriate query selection based on clinical evidence established in the patient medical record.
• Maintains established Productivity Standards Same Day Surgery: 6 accounts per hour Observation: 5 accounts per hour.
• Emergency Room: 12 accounts per hour. Ancillary encounters: 30 accounts per hour.
• Meets or exceeds the expected DRG/APC accuracy rate of 95% Diagnosis and procedural codes applied to accounts result in the appropriate DRG or APC assignment(s)

Coder II

• managing a team that audits, reviews, and codes medical records for the purpose of reimbursement and compliance using ICD-9 and CPT codes
• Develops, implements, and monitors policies, procedures, and systems for proper coding and quality assurance
• Manages workloads, training, and problem resolution
• Oversees all facets of the daily operations and ensures compliance
• Develops and implements systems and processes to establish and maintain records for the operating unit
• Manages projects designed to improve billing practices and increase revenues
• Assists physicians and providers with questions and problems related to coding and billing
• Plans, organizes, and conducts individual and group provider in-service programs
• Conducts quality control studies and audits and implements solutions
• Trains staff on coding, documentation and billing regulations
• Participates in developing, implementing, and maintaining policies and objectives
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Manager, Medical Coding Analysis

• 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

• Identify opportunities to improve provider documentation and create an education plan tailored to each assigned provider
• Arrange educational sessions with assigned providers aimed at quality of care and documentation improvements
• Prepare comprehensive reports and presentations on coding quality trends, risk areas, and educational outcomes using data visualization techniques
• Provider onsite education, based on business needs
• Collaboration with other market provider facing role
• Use data analytics tools to assess coding quality, identify error patterns, and monitor compliance with internal and external standards
• Analyze coding audit results and other relevant data to develop data-driven educational materials and interventions
• Participate in cross-functional teams to improve documentation, data integrity, and workflow processes

Medical Coder

• 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

• Process claims to appropriate primary, secondary, and/or tertiary insurance company according to insurance guidelines
• Perform follow-up on unpaid insurance accounts identified through aging reports
• Process appeals when appropriate
• Process refund requests
• Identify trends, and carrier issues relating to billing and reimbursements, report findings to leadership
• Maintain Privacy & Confidentiality of patient information and organizational operations
• Responsible for learning, understanding and following payer guidelines
• Reallocate misapplied payments and adjustments
• Work special assignments when needed

Medical Billing & Collections Specialist

• 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

• Ensures high quality documentation that is thorough, accurate and complete
• Organizes and prioritizes assigned work
• Reviews charts and medical records, assigning ICD and CPT code combinations
• Audits for documentation opportunities, queries clinical staff
• Contacts physicians for clarification of details
• Utilizes ICD-10-CM classification system and CPT classification system
• Maintains coding accuracy at 90% or better
• Complies with standardized coding standards and regulations
• Participates in specialty specific coding training

Coder RMG

• Code medical records utilizing ICD-10-CM and CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges.
• Review complex medical records and accurately code primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions.
• Coordinate/review the work of designated employees.
• Ensure quality through regular audits.
• Consult and educate physicians on coding practices.

Medical Records Coder II

• 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

• identify opportunities to improve provider documentation and creates an education plan tailored to each assigned provider
• report to the Manager, Medicare Risk Adjustment
• arrange educational sessions with assigned providers aimed at quality of care and documentation improvements
• identify educational needs based on reports
• prepare comprehensive reports and presentations on coding quality trends, risk areas, and educational outcomes using data visualization techniques
• provider onsite education, based on business needs
• collaboration with other market provider facing role
• use data analytics tools to assess coding quality, identify error patterns, and monitor compliance with internal and external standards
• analyze coding audit results and other relevant data to develop data-driven educational materials and interventions
• participate in cross-functional teams to improve documentation, data integrity, and workflow processes

Medical Coding Educator

• 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

Complex Coder, Surgical Cardiology

• Review medical records to identify pertinent HCC codes
• Abstract appropriate information based on guidelines
• Meet productivity and quality performance requirements
• Utilize applications to enter charts coded in real-time

HCC Risk Adjustment Coder

• Coordinate/review the work of subordinate employees and assist with the training and continuing education programs.
• Code medical records utilizing ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges.
• Abstract information from medical records following established methods and procedures.
• Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS and/or CPT coding conventions.
• Ensure quality and quantity of work performed through regular audits.
• Assist with research, development and presentation of continuing education programs on areas of specialization.
• Sequence the diagnoses and procedures using coding guidelines.
• Ensure DRG/APC assignment is accurate.
• Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
• Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply coding guidelines to inpatient and outpatient diagnoses and procedures.
• Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC) etc.
• Assist with special projects as required.
• Perform other related duties incidental to the work described herein.

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