ADDITIONAL LINKS:

This position is Benefit eligible; click here for an overview of available benefits.
This position is covered by the UHP Bargaining Unit; click here to review the current UHP Contract.
This position is in salary group UHP-13; click here to review the current UHP Pay Plan

KNOWLEDGE, SKILLS AND ABILITY:

Extensive knowledge of regulations regarding health care coding, medical documentation of physician services (inpatient and outpatient), billing of professional services to government healthcare agencies and insurance carriers; in-depth knowledge of insurance regulations, utilization management, case management, regulatory requirements, reimbursements and the interface with healthcare billing practices; expert knowledge in government/insurance carrier audit policies and procedures; extensive knowledge of medical specialties and strong clinical background; knowledge of medical records documentation and interpretation of complex medical data; skills in conducting medical/financial audits; strong organizational and presentation skills; excellent interpersonal skills and ability to communicate effectively written and oral; ability to interact with physicians and clinicians at all levels; excellent negotiating skills; strong investigative and problem solving skills; critical thinking skills; ability to influence; ability to prioritize and meet deadlines; and supervisory ability.
EXPERIENCE AND TRAINING: Bachelor’s degree in healthcare related field and five (5) years’ experience in clinical coding (DRG/ICD/CPT) with practical experience in documentation integrity audit processes.
SUBSTITUTION ALLOWED: A Master’s degree in Health Information Management or related field may be substituted for one (1) year of general experience.
SPECIAL REQUIREMENTS: Incumbents are required to have a strong clinical background and may be required to possess and maintain a Certification in Coding from the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) and/or a clinical certification such as RN, etc.

• Schedules, assigns, oversees and reviews the work of staff; provides staff training and assistance; conducts performance evaluations; plans unit workflow and determines priorities, establishes and maintains unit procedures;
• Manages the insurance carrier and governmental claims/medical records audit process including collecting record information from applicable departments, reviewing provider’s documentation against services billed, completeness of the record, accurate billing of services and preparing all audit materials;
• Collaborates with various constituents (i.e. vendors, clinical staff, billing staff, coding staff, compliance staff, clinicians and physicians) to ensure an efficient and seamless response to requests;
• Evaluates audit findings for opportunities to resolve or appeal audit exceptions and coordinates appeal process as needed;
• Identifies coding and documentation issues and recommends necessary corrective action to minimize future related exposure;
• Serves as Chairperson of the Recovery Audit Contractors (RAC) Committee;
• Provides leadership and direction to staff in managing their respective unit’s activities associated with coding, billing and documentation integrity ensuring compliance with regulations;
• Reviews and recommends updates to established policies and procedures relating to the charging, coding and documentation process necessary to meet or exceed government regulations with particular attention to areas currently subject to governmental fraud and abuse focus;
• Ensures appropriate library of references and resources are maintained current by the various offices for support of code and reimbursement documentation requirements for various third party payers with particular attention to federal and state regulations;
• Oversees the maintenance of the related database of questions and responses to audits to ensure uniformity, consistency and high quality of guidance provided to physicians and management;
• Participates in the evaluation and implementation of computer software applications addressing coding or code editing;
• Maintains a high level of technical knowledge and skills related to Diagnosis Related Group (DRG), Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes, documentation standards and billing requirements which are essential to monitor and advise management of general health care industry practices and governmental regulations along with changing areas of governmental fraud and abuse focus;
• Acts as liaison with other operating units, agencies and outside officials regarding unit policies and procedures;
• Performs other related duties as required