Coding Review Specialist

Under limited supervision, the HIM Coding Review Specialist will coordinate, monitor, and audit documentation and coding of inpatient and/or outpatient services in all applicable health care settings. Audits will focus on correct assignment of CPT, ICD-9-CM, HCPSC codes and clinician documentation to ensure that Kaiser Permanente is compliant with all regulatory guidelines and internal controls. Audits will encompass internal practitioners, contracted practitioners, coders, internal facilities and contracted facilities. The HIM Coding Review Specialist will analyze audit results, identify patterns, trends or variations in coding and documentation practices and make recommendations for improvement. When necessary, this position will initiate corrective action plan to ensure resolution of problem areas identified during auditing and monitoring activity. This position will serve as a liaison with HIM staff, Revenue Cycle, External and Internal practitioners, NW Perm, and other regional departments as appropriate including but not limited to IT, benefits, etc.

Essential Functions:

* Perform targeted coding and documentation reviews; correct any deficiencies and prepare report on findings and recommendations. Ensure that all reviews and audits are based on current federal regulatory requirements [e.g. the Centers for Medicare and Medicaid Services (CMS)] and current documentation and coding guidelines, as well as ensuring compliance with departmental/internal policies and other applicable laws and regulations.

* Identify trends and patterns; collate audit results and analyze findings; identify root cause analysis; and identify system issues that may contribute to claims, coding, provider contracting and revenue cycle deficiencies. Prepare written audit report for all noted deficiencies and make recommendations to internal/external departments and others as appropriate/requested (i.e. training, oversight, monitoring, process flows, etc).

* Assist in developing and delivering education and training suggestions, related to the results of the documentation and coding reviews, and findings from RAC and other regulatory audits.

* Assist in the development, implementation and completion of corrective action plans for all noted deficiencies.

* Contribute to the development and maintenance of procedural documentation for internal controls to assist with coding training, education and compliance materials.

* Assist Regional Compliance Department with regulatory audits; collate results and analyze findings. Communicate reports to the HIM Director, Regional Compliance Department, NW Permanente Group, and others as appropriate/requested.

* Regularly collaborate with other HIM/Coding departments, NMF, Regional Compliance, Revenue Cycle, Provider Contracting, external providers/facilities, Claims and other regional departments as appropriate.

* Maintain audit records and tolls for a minimum of 10 years to include audit plans for any given year, audit tools, reports (including recommendations) of all audits conducted, and copies of completed corrective action plans.

Basic Qualifications:

Experience

* Minimum two (2) years of experience conducting coding audits and quality performance measures; preparing audit reports with recommendations; and providing education and feedback to facilitate improvement in documentation and coding.

Education

* Bachelor's degree OR four (4) years of experience in a directly related field.

* High School Diploma or General Education Development (GED) required.

License, Certification, Registration

* Certified Coding Specialist (CCS), Certified Coding Specialist- Physician (CCS-P) or Certified Professional Coder (CPC) (Current maintenance of continuing education/membership is required) required upon hire/transfer.

Additional Requirements:

* Advanced understanding of medical terminology, pharmacology, body systems/anatomy, physiology and concepts of disease processes.

* Advanced knowledge of ICD-9-CM, CPT, HCPCS, HCC/Medicare Risk Adjustment codes.

* Understanding of ICD-10 CM coding.

* Demonstrated ability to provide effective statistical analysis and analytical problem solving.

* Strong working knowledge of the critical elements of the auditing process.

* Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization.

* Knowledge of adult learning principles.

* Well-developed oral and written communication skills.

* Extensive computer experience and ability to learn new computer applications quickly and independently, including: EMRs, Lotus, Microsoft Office Suite and other software products to manage audit data.

* Understanding of CMS HCC Risk Adjustment coding and data validation requirements.

* Ability to manage significant work load, and to work efficiently under pressure meeting established deadlines with minimal supervision.

* Understanding of government rules and regulations and areas of scrutiny for potential areas of risk for fraud and abuse in regards to coding and documentation.

* Ability to obtain 75% or better on Kaiser Coding Skills Assessment for HIM Coding Review Specialist;

* Final candidates will be assessed as part of interview process.

Preferred Qualifications:

* Minimum of five (5) years of coding and /or auditing experience at all coding levels including facility inpatient, outpatient, and professional services as well as three (3) years of project management or related experience.

* Bachelor's Degree in Health Care related field, Health Information Management preferred.

* RHIA or RHIT.

* CHC compliance credential with Health Care Compliance Association. (Current maintenance of continuing education/membership is required).

* Ability to adapt to different work environments and to communicate effectively with a wide variety of individuals at all levels of the organization.