Physician Coding Review Specialist

Licensure, Registration, And/or Certification Required

• Coding Associate (CCA) certification issued by the American Health Information Management Association (AHIMA), or
• Coding Specialist - Physician (CCS-P) certification issued by the American Health Information Management Association (AHIMA), or
• Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or
• Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA), or
• Professional Coder (CPC) certification issued by the American Academy of Professional Coders (AAPC), or
• Specialty Coding Professional (SCP) certification issued by the Board of Medical Specialty Coding and Compliance (BMSC),
• Specialty Medical Coding Certification issued by the American Academy of Professional Coders (AAPC).

• Review assigned codes, which most accurately describe each documented diagnosis and/or procedure according to established CPT, HCPCS, and ICD-10-CM coding guidelines along with modifier usage and medical terminology. Monitor all coding accuracy at various levels of detail and maintain coding quality as needed. Track coding issues and review coding inaccuracies to highlight areas of improvement. Report or resolve escalated issues as necessary.
• Review Clinician documentation and billed codes for Medical Group physicians and non-physician clinicians. Review medical records in collaboration with key stakeholders such as Internal Audit, Compliance, and Clinic Operations. Complete all certified coder quality reviews. Collaborate with Coding Production Leads and Supervisors.
• Follow the prospective and/or retrospective review plan to sample employed Clinician's medical record documentation in comparison to services selected for billing, based on best practice methodologies, which will be presented and reviewed with Clinicians to provide feedback on proper coding and documentation practices.
• Follow the necessary schedules for team assignments of documentation/coding accuracy. Conduct required, timely reviews per the established Clinician Documentation Review Plan and generate summary reports for Professional Coding leadership and the Provider Compliance Committee. Develop mechanisms to identify specific quality issues for each Clinician to allow for focused follow-up reviews to identify improvement/correction of those elements for which the Clinician has received an education.
• Ensure compliance with the system Clinician Documentation Review Plan escalation process for any Clinician who is not successful in meeting the minimum acceptable thresholds. Provide feedback when documentation issues are identified that need improvement. Conduct focused reviews requested by the Compliance department, clinic administration, and Professional Coding leadership. Utilize monitoring tools or other applications to track and report the progress of the Clinician Documentation & Coding Accuracy Plan and for the evaluation of coding quality standards.
• Identify, evaluate and act to resolve any barriers to meeting documentation standards. Provide education/feedback to the department Educators and Coding Liaisons. Maintain coding quality standardized reporting mechanisms. Provide standardized statistical reports of coding quality information to Professional Coding leadership and other appropriate parties.
• Identify and trend coding quality issues/concerns. Recommend coding accuracy improvement strategies, including continued education and/or training plans. Provide feedback regarding coding guidelines, coding protocols/procedures, and system edits to continually improve coding processes and ultimately the overall coding quality program.
• Conduct scheduled and ad hoc coding quality reviews. Conduct regularly scheduled reviews of encounters where coding has been changed or deleted by Coding team members to ensure accuracy and provide education recommendations. Review abstracted and coded encounters for coding accuracy and completeness. Provide feedback on billing system edits as applicable.
• Provide results to Physician Coding leadership and education recommendations as needed. Collaborate with interdepartmental or cross-functional teams for assigned projects and provide departments with coding issues and updates to be shared with Clinicians.
• Utilize chart review results to provide data-driven feedback to clinicians and management to improve coding accuracy and identify opportunities for improvement and re-training. Maintain up-to-date knowledge of Medicare, Medicaid, and other regulatory requirements pertaining to nationally accepted coding policies and standards.

• Advanced training beyond High School that includes the completion of an accredited or approved program in Medical Coding Specialist.

• Typically requires 5 years of experience in expert-level professional coding and at least 3 years of experience in the education of clinicians in…