Quality Assurance Specialist

The Quality Assurance (QA) Specialist is responsible for performance of internal coding QA reviews. These reviews provide an additional layer of internal coding quality and compliance of inpatient (IP) records to assure appropriateness and accuracy of code assignments in accordance with official coding guidelines and client facility specific coding guidelines.

PRIMARY JOB RESPONSIBILITIES:

• Performs IP coding quality assurance (QA) reviews
• Maintains turnaround time expectations to minimize impact to client DNFB
• Maintains an up-to-date working knowledge of MS-DRG, APR-DRG, ICD-10 CM/PCS coding
• Identifies, applies, and validates the use of current industry standard clinical indicators, risk factors and treatment protocols/order sets used in clinical validation of payment impacting code assignment
• Abstracts and performs a comprehensive review of the medical record to assess the documentation present/absent as it compares to the base code set impacting payment, or a requested change in coding
• Review scope includes validation of the MS-DRGs and APR-DRGs assigned for Medicare, Medicaid, commercial, and third-party claims
• Recognizes when a clinical documentation query is necessary
• Writes a query ask with clinical indicators and/or documentation excerpts if a discrepancy or gap exists in the medical record documentation and the (base, desired) code assignment per application of Official Coding Guidelines, or if a medical condition does not appear to be clinically supported or meeting clinical criteria requirements
• Query request writing ability requires knowledge of different types of queries and compliant query practices including knowledge and application of clinical validation criteria
• Develops and maintains a strong understanding of Accuity and of client specific technology, policy, procedures, guidelines, and workflows
• Ensures strict confidentiality of patient information
• Accountable for meeting or exceeding both production and quality expectations
• Meets or exceeds short-term and long-term goals as established for the department
• May require schedule flexibility and change to accommodate workflow and client business needs
• Participates in staff meetings and attends other meetings and seminars as required

POSITION QUALIFICATIONS:

Education:

• Associates Degree required, Bachelor's or Master's degree preferred

Experience:

• Minimum 5 years of hospital inpatient coding and/or inpatient clinical documentation improvement experience required
• Minimum 2 years code/DRG auditing experience preferred
• Experience with electronic health records and health information systems as well as different encoders
• Government program integrity experience preferred
• Demonstrated knowledge of MS and APR-DRGs
• Demonstrated knowledge of all applicable coding clinics as they relate to current IP coding practices

Licensure and/or Credentials/Certifications:

• Health information management and/or coding credential from AHIMA and/or AAPC required (RHIA, RHIT, CCS, and/or CIC)
• CCDS or CDIP certification preferred
• Clinical license preferred (e.g., LPN, RN, BSN, NP, PA, MD, DO, allied health)
• AHIMA ICD-10/PCS trainer certification preferred

Knowledge, Skills, and Abilities:

• Expert knowledge of Official Coding Guidelines, advanced knowledge of APR and MS DRG reimbursement models, state, and federal regulations
• ICD-10-CM/PCS coding expertise including POA assignment and discharge disposition codes
• Knowledge of AHRQ Quality Metrics including patient safety indicators (PSIs), Hospital Acquired Conditions (HACs), Vizient Mortality Models, CMS Core Measures, other national patient safety quality indicators, and different payor categories
• Knowledge of quality assurance/healthcare internal auditing concepts and principles
• Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, disease assessment, patient management, and treatment
• Knowledge of legal, regulatory, and policy compliance issues related to medical coding and documentation
• Knowledge of current and developing issues and trends in medical coding diagnosis and procedure code assignment
• Advanced knowledge of medical coding, electronic medical record systems, and coding systems
• Ability to use independent judgment and to manage confidential information
• Ability to analyze and problem solve
• Detail oriented with ability to multi-task
• Strong communication (written and oral) and interpersonal skills
• Ability to clearly communicate information to coders, physicians, and CDI staff
• Ability to provide guidance and training to Accuity coding, physician, and CDI staff
• Independent, focused individual who takes initiative and can work remotely
• Able to execute under the pressure of time constraints and maintain focus over period of work hours
• Demonstrates ability to work independently as well as cooperatively with various teams
• Serves as a professional role model for internal and external customers
• Certifications and/or professional license must be maintained as a condition of employment
• Maintains subject matter expertise in clinical validation criteria and practices, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies as a condition of employment
• Ability to use a PC in a Windows environment, including MS Office applications
• Independent, focused individual able to work remotely or on-site