The Senior Clinical & Coding Specialist will manage ongoing Inpatient Medical Admission and Readmission audits, validating diagnosis and procedure coding against documentation and ensuring compliance with ICD-10 guidelines and financial policies. They are also responsible for handling all reconsideration clinical appeals and serving as the subject matter expert for audits, including research for policy revision.
Requirements summary
A minimum of an Associate's degree is required, though experience can substitute, and a Bachelor's degree is preferred; candidates must possess at least one specified certification (e.g., CIC, RHIA, RN/LPN) and four years of experience in a clinical setting or utilizing ICD-10 coding systems. Required skills include proficiency in ICD-10 coding, analytical thinking, process management, and strong communication abilities.
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Overview The Clinical & Coding Specialist-Senior will be responsible for reviewing coding and clinical decisions on cases involving complex clinical presentation with correlating coding complexity.
They will aid in training other team members, evaluating appeals, and share audit trends across the team.
Expertise and proficiency demonstrated by long-standing, consistent results, advanced coding knowledge and auditing skills evidenced by their ability to train others, to identify coding patterns and share knowledge and audit tips across the team.
The Clinical & Coding Specialist-Senior will support the leadership in Hospital Audit in accomplishing all aspects of the audit plan.
Qualifications Associates degree required.
Bachelor’s degree preferred.
An additional two (2) years of experience will be considered in lieu of degree.
Minimum of one of the following certifications or licensures: Certified Inpatient Coder (CIC), Registered Health Information Management Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Clinical Documentation Specialist (CCDS), American Health Information Management Association (CCS-H, CCS-P), Certification Denials and Appeals Management (C-DAM), or NYS licensed RN or LPN required.
LPN or RN preferred.
Four (4) years of experience working in a clinical setting or utilizing a coding system (ICD-10 or PCS) required.
Coding audit experience in an inpatient setting preferred.
Knowledge of ICD-10-CM and ICD-10-PCS coding systems, as well as respective reimbursement methodologies associated with each coding system preferred.
Experience and proficiency reviewing health care delivery against clinical quality, as well as financial established guidelines.
Analytical and critical thinking skills.
Ability to ensure that clinical information translates correctly into claim coding compliance with requested data set.
Ability to prepare quantitative and qualitative studies at conclusion of audit.
Benefits
Full range of benefits
Ability to recalculate reimbursement following conclusion of audit in accordance with corporate provider contracts and/or Independent Health policy and procedures.
Autonomous/independent worker, minimal supervision, including process management skills.
Subject matter expert in all coding systems and/or inpatient clinical expertise.
Ability to serve as effective team member of cross-functional teams and/or proven ability to facilitate teams and foster collaboration internally and externally.
Understanding of organizational business strategies as well as audit and reimbursement related business strategies.
Organizational skills, verbal & written communication skills with ability to effectively communicate with personnel and providers externally.
PC/Windows skills with proficiency in Microsoft Word and Excel.
Experience with remote access - citrix, VPN, external EMR access.
Knowledge of facility contract reimbursement policies.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative, and Accountable.
Essential Accountabilities Assume role of project manager as it relates to the re-engineering of the hospital audit process.
Responsible for the ongoing management of Inpatient Medical Admission and Readmission audits to include trends of clinical findings and financial recoupment statistics.
Perform validation of diagnosis and procedure coding by reviewing medical record documentation and/or provider claims data.
Ensure coding compliance with industry standard ICD-10-CM and ICD-10-PCS coding guidelines and financial policies/contracts.
Responsible for all reconsideration clinical appeals to include review of records, consultation with Medical Director, response to facilities as well as coordination of all aspects of these functions for external review agent process (Dispute Resolution Agency).
Serve as the subject matter expert for each audit to include internet research of industry standards (clinical/coding), that may be used to assist in the creation or revision of Independent Health policies and procedures.
Prepare and present audit results as needed, to various levels of internal senior leadership for approval of financial recoveries, provider education, and/or recommendation for next steps.
Immigration or work visa sponsorship will not be provided for this position Hiring Compensation Range: $33.50 - $38.00 hourly Compensation may vary based on factors including but not limited to skills, education, location and experience.
In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off.
The base salary range is subject to change and may be modified in the future.
As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.
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Current Associates must apply internally via the Job Hub app.
The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being.
Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation.
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