Medical Coding Reviewer
The Medical Coding Reviewer supports the Centers for Medicare and Medicaid Services (CMS) by identifying improper payments made under Medicaid and the Children's Health Insurance Program (CHIP). This position utilizes a medical coding background to increase efficiencies in the Federal government by conducting in-depth reviews of fee-for service (FFS), managed care and eligibility records; and then produces error rates based on the reviews.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge/quality of work, supporting financial goals of the company, initiative/motivation, cooperation/relationships, problem analysis/discretion, accomplishing goals through organization, positive oral/written communication skills, leadership abilities, commitment to Affirmative Action, reliability/dependability, flexibility and ownership/accountability of actions taken.
Understands and abides by security and Health Insurance Portability and Accountability Act (HIPAA) policies, including patient information confidentiality.
Reviews electronic images of medical records to determine accuracy of coding.
Performs second level Inter-rater Reliability (IRR) and Difference Resolution (DR) reviews, as needed.
Accurately documents findings in State Medicaid Error Rate Findings (SMERF) system.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions to the best of own ability.
Associate’s degree and a minimum of three (3) years relevant experience in a clinical setting evaluating appropriateness of diagnosis and procedure coding and their appropriateness in clinical settings, or equivalent combination of education / experience. Experience with Medicaid and/or CHIP at a state or national level required.
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
- Working knowledge of standardized coding review criteria, including Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) codes
- Operational knowledge of computers with skilled proficiency in the use of Microsoft Office Suite and the ability to quickly grasp customized software systems
- Ability to manage multiple projects and priorities with ability to meet specified deadlines
- Excellent verbal and written communication skills
- Excellent customer service and relationship-building skills
- Ability to effectively work independent of supervision
CERTIFICATES, LICENSES, REGISTRATION
Nationally recognized medical coding certification (i.e., AAPC Certified Professional Coder (CPC), AHIMA Certified Coding Specialist (CCS), etc.)
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.