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Manager Hospital Coding Assurance

VIRTUAL-GA • Atlanta, Georgia • Day Shift • Full Time • JR-6260

Job Summary:

Under the direction of the Director of Coding Assurance - Compliance, the Manager of Hospital Coding Assurance is responsible for executing the Wellstar Health System Compliance Plan within the Coding Assurance Compliance Team. This person will lead WellStar's Inpatient and Outpatient Coding auditors in proactively identifying risk and addressing compliance issues as they pertain to coding/billing within the Wellstar Inpatient / Outpatient hospital populations. This department conducts regular audits and monitors activities to promote compliance with federal regulations related to the Federal Healthcare Programs (i.e. Medicare and Medicaid and others). This team provides compliance education with an emphasis on coding and billing regulations for Hospital services in Wellstar facilities. This person will coordinate the above audits/education, research and respond to compliance and other coding / billing related questions and prepare communication/responses both in verbal and in written formats. This person will be responsible for coordinating internal reviews, compliance training as well as targeted educational programs throughout each year. This team will look for trends in coding and billing patterns and provide comparative benchmarking to ensure optimal reimbursement while remaining in compliance with published guidelines and regulations. This person must be able to work independently, motivate a strong team, and must have professional communication skills both verbally and in writing.

Core Responsibilities and Essential Functions:

Manage Hospital Coding Assurance Audit Process - Implement and maintain audit controls and measurements for internal processes. - Develop management reports showing the results of the audit process. Works with the Director of Hospital Coding Assurance, Coding leadership, and other departmental leads as appropriate in developing action plans and follow-up initiatives to address the opportunities identified through the annual audit process. - Develop training and educational material associated with identified risk or audit findings. - Assist Director in providing oversight and leadership surrounding external audits. - Ensure correct processes are in place for accurate, complete and compliant coding/billing across hospital billing to include but not limited to the following: - Billing for items or services not rendered or not provided as claimed - Submitting claims that are not reasonable and necessary - Billing for non-covered services as if covered - Identification of risk areas involving Inpatient Admission criteria - Unbundling - Failure to properly use modifiers - Submitting claims with diagnoses / procedures not documented in the medical recordUpcoding / overcoding / undercoding - Failure to apply correct coding practices for Inpatient populations Manages communication from the Hospital Coding Assurance Team to Compliance and Coding leadership: - Chart documentation deficiencies and opportunities for improvement that may result in over coding and/or under coding - Trends in RAC or other governmental audit findings - Federal and state regulations governing billing (medical necessity, Inpatient Admission Criteria, etc) - National/Local Coverage Determination and Official Coding Guideline reviews appropriate for the procedure /test in question - Trends in denials - Results of benchmark comparisons such as PEPPER reports. - Claim issues involving hospital services (may need to incorporate other departments such as: PFS, Revenue Management, and other hospital departments as needed) Assists the Coding Assurance Director in developing, coordinating, and management of Annual Audit plan - Reviews OIG annual workplan - Identifies areas of focus related to WellStar services - Works with management teams in focus areas to complete risk assessment - Consolidates findings and creates recommendations for presentation to executive leadership team - Conducting investigations surrounding reports of coding/billing violations or other compliance related issues . - Assist with the development of corrective action plans. - Ensure the appropriate disclosures are completed and submitted. Communication of new/revised regulations/requirements - Provide support and guidance regarding implementation of new regulations as related to site dpts - Provide support and guidance regarding action plans for deficiencies - Provide regular updates to Administrator, Directors, medical staff, and managers regarding - regulatory requirements and continuous monitoring - Maintains active issues log to ensure timely response, resolution, and follow-up Requests and collects data on population for sampling - Analyzes data and selects sample - Utilizes Microsoft Access and Excel to collect/analyze/report findings/trends - Creates executive summary with findings and recommendations. References governmental regulations where needed. - Conducts exit conference with staff, physician, and executive leadership team when appropriate - Works with external agencies to coordinate/review documentation supporting services provided and billed - Prepares disclosure documentation as needed - Manages organizational structure supporting review functions - Performs complex data analytics Provides Education - Provides post review follow-up education with WellStar employees, management and physicians - Provides education on new releases from Medicare and Medicaid - Answers compliance/documentation/coding/billing questions via e-mail - Maintains education log - Provides 3rd-party software training, support, and guidance for team member audit functions Coordinates Internal Process for Medicare Recovery Audit Contractor (RAC) and other Governmental Focused Reviews - Facilitates the Recovery Audit Contractor software implementation and response team. - Develops workflows, policies and procedures, and the communication plans to prepare and manage the RAC requests and denials. - Monitors overall effect of RAC on the WellStar facilities and reports results of requests, denials, appeals, risks, and opportunities on a regular basis to leadership. - Develops action plans and coordinates multidisciplinary teams for performance improvement. - Assumes a leadership role with the interdisciplinary teams to achieve optimal outcomes (includes RAC Task Force). - Analyzes RAC data to determine trends in documentation, coding, billing to improve organizational practices, policies and procedures, and to maintain integrity and compliance with all federal programs.

Required Minimum Education:

Bachelor's Degree in Health Information Management, Business Required or other health care Required or business-related field Preferred

Required Minimum License(s) and Certification(s):

Cert Coding Spec 1.00 Required Cert Coding Spec - Phys Based 1.00 Required Cert Prof Coder 1.00 Required Cert Prof Coder - Hospital OP 1.00 Required Reg Health Information Admin 1.00 Required Reg Health Information Tech 1.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 5 years of inpatient auditing, and/or other related coding/billing/compliance related experience Required and Outpatient coding experience Preferred

Required Minimum Skills:

Extensive knowledge of medical terminology, CPT-4 procedural coding (including Level II HCPCS), ICD-9-CM coding, ICD-10-CM, ICD-10-PCS and all coding and billing guidelines. Hospital billing experience with focus on government payors. Extensive experience with medical record chart review and/or extraction for hospital billing. Extensive experience with Medicare, Medicaid, and reimbursement rules and regulations. Experience with management information systems and medical software. Competent in Microsoft Word and Excel software in a Windows environment (Experience with Microsoft Access Is a plus).

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