SUMMARY: Responsible for the operational functions of the Coding Quality and Education program, which includes annual provider audits, coder accuracy monitoring programs, and implementing coding education initiatives, for all professional services coders and medical staff at Alameda Health System (AHS) and Alameda Health Partners (AHP); plays a strategic role in validating the accuracy of CPT, HCPCS and diagnosis code assignment by coders, physicians and non-physician practitioners, and compliance with governmental regulations, coding guidelines, and reporting requirements; actively involved in the dissemination of coding requirements and updates to appropriate stakeholders; works closely with Patient Financial Services to understand reasons for denials, root cause analysis, and feedback to providers; develops and implements coding training plans for the organization, including curriculum development, preparation and delivery of training, to improve the accuracy, integrity and quality of patient data, and to improve the quality of provider documentation within the body of the medical record to support code assignment.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Responsible for the day to day management of the audit and education team members which includes implementing and maintaining staff productivity and quality standards.
2. Implements annual provider audit programs to evaluate compliance with policy, coding (ICD-10, CPT and HCPCS), billing (NCCI, etc), and regulatory (CMS) requirements.
3. Partners with Health Information Management (HIM) coding management in developing strategy and programs to address non-compliant or high-risk coding practices.
4. Assesses professional coding and patient care documentation practices to monitor compliance with pertinent regulations and guidelines.
5. Monitors and reports status of internal or regulatory generated billing and coding audits.
6. Partners with HIM coding management in developing recommendations for corrective action plans and creates policies, procedures, and internal controls which reinforce the highest level of standard of coding quality.
7. Monitors through auditing, evaluating the effectiveness of education and training programs.
8. Participates in new provider orientation by providing education, auditing and training.
9. Identifies trends, patterns and variances in coding and documentation and provides education where necessary.
10. Partners with Patient Financial Services (PFS) Denials Management to determine root causes and provide feedback and training to providers in order to reduce denials.
11. Reviews all educational materials for accuracy and chooses methods of education that are appropriate and effective.
12. Partners with HIM coding management to develop coder training programs (e.g. new coder/specialty, continued training, etc.)
13. Partners with HIM coding management on coding initiatives (e.g. edits reduction, etc.) and educate providers accordingly.
14. Monitors and tracks quality metrics to support functions of the coding team are performed with a high degree of accuracy.
15. Stays abreast of coding/billing regulatory requirements and company compliance policies, ensuring timely staff education.
16. Manages the delivery of communication and coding training to various groups, including leadership teams, providers, and coders; delivery methods may include instructor-led, train-the-trainer, virtual classroom, web-cast, or web-based methodologies.
17. Researches, summarizes and disseminates information regarding new coding requirements (e.g. annual CPT code updates, etc.) and update appropriate management, providers and coding staff of changes.
18. Serves as a resource for department managers, physicians, and administration to obtain information and clarification on accurate and ethical coding standards, guidelines and regulatory requirements.
19. Partners with the Revenue Integrity Director in structuring the coding education program so that the education targets the findings of the quality audits and coding reviews.
20. Evaluates and implements opportunities for enhancing cost effective delivery of services.
21. Utilizes Lean Management to develop standard work and continuous process improvement within the department.
22. Performs other duties as assigned.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
+ Required Education: Bachelor's Degree in Finance, Business Administration or Health Related field or the equivalent combination of training and experience required.
+ Required Experience: Five years experience with two years supervisory experience, to include healthcare experience in coding, billing and collections in a hospital/ambulatory setting.
+ Required Licenses/Certifications: AHIMA or AAPC Coding Certification (CCS-P, CPC, COC, or CPC-P).