Claim Review Specialist

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product.  Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team.   Client education, written FAQ answer preparation, and other duties as assigned.

This is a remote position

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Reports To: Director of HIM/Audit Services (RCM Services)

Location:  Remote USA; work from home office

FLSA Status: Full time, exempt

Summary:  Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product.  Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team.   Client education, written FAQ answer preparation, and other duties as assigned.

QUALIFICATIONS

• 5+ years of current directly related experience

• Expert knowledge in revenue cycle and Outpatient coding (ER, SDS, OBS, ancillary, IR, Profee, E/M facility, I&I)

• CCS, COC or CPC certification required

• Medical Terminology and anatomy knowledge is required

• Clinical Documentation and Inpatient coding experience is preferred.  New hires will be expected to learn IP during employment. 

• Must have strong understanding of revenue cycle, CMS Manual/guidelines, Medicaid guidelines.

• Strong Microsoft Excel, PowerPoint, Word and OneNote skills

• Must have strong understanding of the Official Coding Guidelines, OP coding and billing (i.e. including but not limited to knowledge of rev codes, HCPCS, MUE and CCI edits, UoS and ICD-10 CM)

• Strong analytical capability, independent thinker and good decision-making skills

• Excellent written and verbal communication and presentation skills

• Strong computer and technology knowledge and skills

• Highly professional demeanor, great client satisfaction skills

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Become proficient in the use of the PARA Data Editor, our proprietary software;

• Select and review claims for review based on trends/data analysis in the PARA Data Editor; organize information and access to medical documentation. 

• Audit all aspects of claim including (but not limited to):

-Omitted or incorrect charges,

-Review OPPS and CAH charges and apply guidelines.

-CMS/Payer specific guidelines

-Coding accuracy for ICD-10 CM, CPT/HCPCS (including but not

limited to 10000-69999, 80000, 90000, J codes, G codes, Q codes,etc)

-Departmental review for inaccuracies, omitted data/documentation

and charges

-NCCI edits, MUE edits, Medi-cal and Medicare guidelines/CMS

Manual guidance,

-Units of services

-E/M Profee/Facility

-Units of services

-Documentation improvement.

• Assist in preparing written documents for publication under the direction of the Director, HIM, i.e., Q&A entries.

• Develop a working understanding of the outpatient hospital reimbursement process, including documentation, coding, and billing.

• Participate in presentations to clients and prospective clients, typically over web meetings.

• Develop and maintain the skills and knowledge necessary related to the assigned specialty areas and the related services. Keep current on all related information from journals and bulletins. Distribute and pass on all necessary materials, including copying for reference files when relevant.

• Maintain current certifications and accreditations (as applicable).

• Research new guidelines, data elements, payer specifications, etc. 

• Other duties may be assigned as necessary.

This is a remote position

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.