Under the direct supervision of the Billing and Coding Compliance Manager, and indirect supervision of the Associate Director of Billing and Coding Compliance, conduct research and detailed analytical reviews to determine the accuracy of UB-04 (facility) claims by evaluating medical record documentation and facility claims for compliance with CPT, HCPCS, ICD-10 codes, modifiers, DRG and APC assignment. Independently analyze and communicate Federal and State regulations related to inpatient and outpatient facility billing requirements. Analyze and evaluate the accuracy of the billing process and conduct strategic risk assessment in order to ensure compliance.
Responsible for communicating UCSD Health's coding compliance standards and procedures, and for providing guidance and clarification related to coding questions to support accurate billing – to employees and to authorized representatives of UCSD Health's billing agents. Serve as a subject expert to Patient Financial Services on complex billing situations and provide guidance on compliance related matters such as laws, regulations and programs. Perform and analyze data/reports from compliance monitoring activities to identify trends, issues, and risk areas. Advise on issues relating to regulatory matters.
Work cross functionally with the continuous documentation improvement team, revenue cycle and health information to proactively identify risks and respond to identified issues. Assist with coordination of responses to and resolutions of external investigations and audits. Responsible for monitoring billing, coding and related claims submission changes and updates from the Centers for Medicare and Medicaid Services (CMS), Medicare Administrative Contractor (MAC), Beneficiary and Family-Centered Care (BFCC) QIO, Medi-Cal and other related government entities. Develop presentations, audit summaries and process improvement plans. Perform other related duties as assigned.
Bachelor's Degree in related area; and/or equivalent combination of experience/training.
A minimum of three (3+) or more years of relevant experience.
Demonstrated knowledge and experience of DRG/APC validation process.
Demonstrated knowledge of coding guidelines and conventions.
Knowledge of national quality standards, state and federal laws relating to review for coding validation, and knowledge of a variety of clinical specialty areas of medical treatment, practice,
Proven ability to audit key documents to ensure correct and appropriate codes are being assigned and utilized.
Strong analytical, problem solving, critical thinking, and organizational skills.
Superb written, oral, presentation, facilitation, and interpersonal communication skill. Ability to communicate effectively across all levels of the organization.
Excellent, fast, accurate computer skills using Microsoft Office applications. (Excel, Word, PowerPoint).
- Current coding credentials (CCS, CIC, COC), or health information professional (RHIT, RHIA) from a nationally recognized program (AHIMA, AAPC).
- Experience in acute care and ambulatory coding.
- Certified in Healthcare Compliance.
- In-depth knowledge and ability to conduct comprehensive review of patient records for appropriate medical record documentation of CPT/ICD-10/HCC coding, APC and DRG assignment.
- Must be able to work various hours and locations based on business needs.
- Employment is subject to a criminal background check and pre-employment physical.
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