Coding & Payment Compliance Specialist - St. Josephs Candler

• Position Summary
  • This position is responsible for ensuring coding and payment accuracy for outpatient hospital services performed at St. Joseph’s/Candler Health System. Coding & Payment Compliance Specialist must be able to assign HCPCS, CPT codes and modifiers to outpatient encounters including emergency department visits, clinic visits, oncology treatment visits, recurring outpatient therapy and infusion center visits, diagnostic exams and testing, and laboratory reference accounts. The Coding & Payment Compliance Specialist serves as a liaison to clinical departments, Health Information Services (HIM), Physician Revenue Cycle and Pt Financial Services (PFS) to resolve claim edits and line item denials. The position is responsible for reviewing and resolving charge line item denials and identifying opportunities to prevent avoidable denials. Attention to detail is required for accurate capture of data elements, knowledge of coding and billing regulatory guidelines, and billing rules, commitment to ethical and compliant coding practices.
• Education
  • Associate's degree in Health Information Administration or similiar Healthcare related degree - Preferred
• Experience
  • 3-5 Years Coding, Healthcare Billing, Claims Processing, Denials Management, Payment Processing or comparable experience - Required
  • 1-2 Years Outpatient Coding - Preferred
  • Proficiency in using and creating of data using Excel spreadsheets, preparing and presenting materials, reports or data using PowerPoint, Excel and other similar tools; attention to detail - Required
  • Working knowledge of Centers of Medicare and Medicaid (CMS) billing regulations - Required
• License & Certification
  • Certification by American Health Information Management Association (AHIMA) CCA, RHIT, RHIA, CCS; or certification by the American Academy of Professional Coders (AAPC) CPC or COC or comparable medical coding certification - Required
• Core Job Functions
  • Accurately reviews and resolves charge line denials to ensure proper billing and coding of outpatient hospital services for the health system. Collaborates with clinical departments, PFS, HIM and other revenue cycle departments to ensure appropriate rebilling of claims for denials, when appropriate. Identifies and collaborates with others to develop workflow and process improvements to prevent claim denials and incorrect payments
  • Utilizing the tools including Meditech, 3M and Trisus reference, resolves all national correct coding and outpatient code claim edits; and appends appropriate modifiers to CPT and HCPCS codes. Ensures documentation is reviewed and supports billing of services, modifiers, etc. for claims.
  • Reviews and resolves Meditech tasks assigned to Revenue Integrity including claim-line denials, quantity denials and other billing or charge related claim line issues. Identifies trends and provides recommendations to Senior RI Analyst and or Director on process implements to prevent denials.
  • Conducts post billing audits to identify revenue capture opportunities and potential payment compliance risks. In conjunction with the Director, prepares formal report of annual payment compliance work plan.
  • Provides assistance to other Revenue Integrity coworkers on daily and weekly essential functions when needed. This includes, but not limited to, assistance with charge entry, pre and post bill audits, claim edits, MT account checks and other duties as assigned.
  • Follows the standards of professionalism set forth by AHIMA and AAPC. Ethically and accurately assigns CPT/HCPCS procedure codes and modifiers in accordance with the CPT guidelines and Trisus Reference guidance. Maintains certification and engages in continuing education activities. Stays up-to-date on regulations including national and local policies. Shares knowledge with the rest of the team.

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