Not a remote position
Clinical Experience a MUST

The role of the Clinical Coding/Documentation Improvement Specialist (Quality Improvement/Medicare Risk Adjustment – QI/MRA/UM/Care Coordinator) is to monitor and audit medical record documentation, coding and quality measures, utilization and billing in the Practice offices. It is crucial for this role to have knowledge of 5 STAR, PQRS, HEDIS, CMS coding and billing guidelines, clinical standards, practice guidelines, utilization management knowledge, and outcomes management skills.

This position requires knowledge of ICD-9/ICD-10, CPT, and documentation guidelines, along with clinical skills and practice management knowledge to assist in coding and documentation audits and billing functions as determined by Compliance, Operations, and/or Quality departments. The role ensures all quality measures for patient populations for Managed Care and Medicare are completed annually. Additionally, the specialist performs analytics on Practice expenditures for clinical care and manages utilization appropriately.

Skills:

Communication and accurate coordination of information
Critical thinking, problem solving, computer, and EHR system proficiency
Clinical background and practice management skills
Understanding practice clinical guidelines
Ability to travel
Ability to read and analyze medical records
Ability to perform clinical correlations
Proficiency with ICD-10, CPT codes, and QIP measures; CPC or CSSP necessary
Understand coding and billing guidelines
Understand principles of care management

Duties and Responsibilities:

Perform audits of documentation, coding, and billing practices as required
Follow recent documentation and coding guidelines
Use pre-approved documents for validation
Query providers for coding specificity
Create and maintain Chronic Condition Lists for PCPs
Assist with missing condition reports from carriers
Support quality measures initiatives by capturing data
Assist in analysis and planning regarding utilization
Support care coordination and case management
Educate office staff and providers on documentation and coding
Report issues to Quality, Compliance, and Operations
Perform coding/documentation reviews and assist with departmental strategies

Education and Experience:

Prefer clinical background
Current ICD-10 coding certification or equivalent
1-2 years of coding experience in any medical field or demonstrate proficiency via interview coding test
Experience with MRA reimbursement structure required
Must obtain CPC certification within 1 year of hire

Language Ability:

Ability to read and comprehend instructions and correspondence
Ability to write simple correspondence
Ability to present information effectively to providers, staff, insurance companies, and employees

Computer Skills:

Proficiency with Microsoft Word, Excel, Internet, Email, and insurance websites

Work Environment:

Moderate noise level

Physical Demands:

Close vision ability required
Regularly sit, use hands and arms, talk, and hear