Professional Services - Medical Coding Quality Assurance Specialist

We are seeking a Medical Coding Quality Assurance Specialist. This position performs highly technical and specialized functions for Capstone. The Medical Coding Quality Assurance Specialist performs quality audits for coding data to ensure compliance with Coding guidelines, as well as departmental policies and procedures. The primary function of this position is to ensure compliance in maintaining 95% coding accuracy for all coding staff. Additionally, this position analyzes findings and provides feedback and support for training and clinical documentation improvement.

POSITION RESPONSIBILITIES

Primary Functions:

• Performs validation audits and interpretation of medical documentation to ensure capture of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives.
• Performs quality reviews of coding vendor and/or coding team work activities to ensure all collected data is accurate, complete, and compliant with state and federal regulations as well as Official Guidelines for Coding and Reporting and Capstone defined coding policies and procedures.
• Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
• Identifies and reports issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding guidelines and CMS HCC Categories
• Assigns and sequences ICD codes to diagnoses for documented information. Performs final review and revision of ICD-10 codes in Client’s EMR. May perform ICD-10 code entry when necessary into client’s EMR.
• Maintains 95% accuracy rate.
• Appropriately uses coding principles to code to the highest specificity and complies with CMS regulations and company goals and policies.
• Upon completion of audits, compiles detailed findings and prepares reports.
• Provides audit results and shares recommendations for course-correction and education as needed. Analyzes coded data to determine trends and root cause for variations.
• Performs reviews for prospective and retrospective audits when requested.
• Participates in workgroups/committee meetings and process improvement solutions as required.
• Advises Director of Coding and Auditing of possible trends in inappropriate utilization (under and/or over) and other quality of care issues.
• Maintains professional license and certifications and attends training conferences/webinars as necessary to keep abreast of latest trends in the field of expertise.
  

Qualifications:

Education and Certifications:

Required:

• Certified Coding Specialist designation (CCS) issued by the American Health Information Management Association; or, Certified Professional Coder (CPC) or Certified Technologist (RHIT)

Experience and Training:

Minimum 3 years coding experience (except RHIT) with a minimum of 2 years’ experience with Risk Adjustment Coding (HCC)