Lead Coder – Risk Management
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Job Description
Coder Lead overseeing coding compliance in Risk Management for Advocate Health. Training and directing coding team, ensuring quality standards are met with ICD, CPT, and HCPCS.
Responsibilities:
- Acts as a resource and role model to team members, which includes training/orienting, providing day-to-day work direction, and giving input on performance
- Assigns, monitors, and reviews progress, quality and accuracy of work, monitors productivity, maintains appropriate staffing levels, directs efforts and provides guidance on more complex issues
- Codes routine to complex procedures and diagnoses including hospital-based or surgery center surgical procedures using ICD, CPT, and HCPCS coding guidelines, procedures and protocols for government and commercial payers
- Meets or exceeds department quality and production standards
- Performs informal quality reviews on a monthly basis providing coding education to coding team members for accuracy
- May assist with provider education/orientation regarding policy requirements of federal and state government agencies
- Abstracts documentation to choose correct ICD, CPT, HCPCS codes according to standard coding guidelines, procedures and protocols
- Detects, reports and acts as a resource to assist in resolving billing compliance issues
- Serves as liaison between business office, medical records, patient care and/or coding department by providing feedback to caregivers and leaders
- Responsible for processing denial management claims and addressing patient concerns
- Serves as a resource to caregivers regarding pre-authorizations, referrals, and estimating charges prior to a patient's visit
- Coordinates payer audit reviews and acts as a resource for coding-related audits
- Participates in various department projects including but not limited to researching new services, claim scrubbing, quality checks/assessing errors, presenting demonstrations, etc.
- Acts as the system/application administrator; ensures the integrity of the system and recognizes performance issues
- Performs calibration and troubleshooting procedures and escalates unresolved issues as needed
- Suggests modifications to current policies and procedures that are needed to coincide with requirements of insurance payers
- Serves as subject matter expert in your assigned specialty and actively participate in the Coding meetings as a problem solver
- Adhere to organizational and internal department policies and procedures to ensure efficient work processes
- Expertise in query guidelines, and coding standards
- Follow up and obtain clarification of inaccurate documentation as appropriate
- Reviews complex medical documentation at a highly skilled and proficient level from clinicians, qualified health professionals and hospitals in order to assign diagnosis and procedure codes utilizing ICD-10 CM/PCS, CPT, and HCPCS
- Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations utilizing an EMR and/or Computer Assisted Coding software
- Abides by the 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 the confidentiality of patient records
- Reports any perceived non -compliant practices to the coding leader or compliance officer
- Achieves productivity expectations to support discharged not final billed (DNFB)
- Assist in the production of annual edit review based on CPT, ICD and HCPCS changes as well as assist in development of edits based on publications and society updates
Requirements:
- Certification required: Coding Certification issued by one of the following certifying bodies: American Academy of Coders (AAPC), or American Health Information Management Association (AHIMA)
- Advanced training beyond High School that includes the completion of an accredited or approved program in Medical Coding Specialist (or equivalent experience)
- Typically requires 7 years of experience in professional coding that includes experiences in revenue cycle processes and health information workflows or related health care leadership experience
- Knowledgeable in researching coding related topics and issues
- Advanced proficiency of ICD, CPT and HCPCS coding guidelines
- Advanced knowledge of medical terminology, anatomy and physiology
- Excellent computer skills including the use of Microsoft office products, electronic mail, including exposure or experience with electronic coding systems or applications
Benefits:
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
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