- Conduct UPMC wide auditing and monitoring to ensure coding/documentation combinations and medical record documentation adequately supports services coded and billed in accordance with the appropriate state and federal regulations and/or standards.
- Validate the ICD-10-CM, CPT, and HCPCS codes or CPT and HCPCS ICD-10-CM-PCS DRG assignment appropriateness to ensure consistency and efficiency in claims processing, data collection, and quality reporting.
- Conduct audits on other compliance related topics as determined to evaluate compliance with the state and federal laws, regulations and policy
- Develop concise and well referenced audit workpapers.
- Communicate to key stakeholders regarding audit findings and corrective actions.
- Prepare written reports of audit results, including recommendations for improvement and compliance with state and federal laws and regulations.
- Advise leadership on regulatory requirements for coding documentation and billing to ensure services are submitted according to payor guidelines and related regulations.
- Maintain current knowledge and understanding of regulatory trends and changes in coding policy and reimbursement methods.
Conduct post-audit compliance training sessions for physicians and non-physician practitioners as audit results dictate. These training sessions will include, but are not limited to, provision of education specific to the issues found on audit and will be largely based on the documentation, coding and billing rules as set forth by CMS and other relevant Federal and State regulatory agencies.
- High School Diploma or equivalent required. Associates Degree or higher or comparable technical school diploma is required.
- 4 or more years of experience in medical coding, billing, auditing and compliance. Extensive knowledge of CMS, and third-party payer coding, billing, and documentation compliance regulations required (MS-DRG, APR-DRG, APC, APG, or ICD10-CM, HCPCS, CPT, Modifiers, etc.).
- Knowledge of coding/classification systems appropriate for inpatient /outpatient, DRG prospective payment system or office setting E/M codes.
- Experience in an academic medical center setting is strongly preferred. Knowledge of key revenue cycle processes, and clinical documentation is strongly preferred.
- Proficiency with associated technology solutions such as Microsoft Excel, Word and PowerPoint is required.
- Must be able to demonstrate a high degree of professionalism, enthusiasm and initiative daily.
- Must have strong interpersonal, organizational, analytical and communication skills.
- Ability to work in a fast-paced environment.
- Must have ability to manage multiple tasks and projects, and forge strong interpersonal relationships within the department and with other departments. Ability to identify, interpret and summarize relevant policy and regulation in a clear and timely manner is essential.
- Experience researching and interpreting regulation and performing internal investigations is essential.
- Attention to detail is critical to the success of this position.
- Excellent planning, communication, documentation, organizational, analytical, and problem-solving abilities.
Data Analytics experience is strongly preferred.
Licensure, Certifications, And Clearances
Certified Coding Specialist (CCS)Certified Inpatient Coder (CIC) Certified Evaluation & Management Coder (CEMC)Certified Professional Medical Auditor (CPMA)Certified Professional Coder (CPC)Certified Medical Coder (CMC)ORRegistered Health Information Administrator (RHIA)Registered Health Information Technician (RHIT)ORLicensed Professional Nurse (LPN)Registered Nurse (RN)
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