Under the general direction and supervision of the Health Information Director/Designee, the Compliance Reimbursement Specialist is responsible for analyzing documented clinical data to identify cases where additional provider documentation is needed to better reflect the patient’s clinical picture, severity of illness, etc. In addition, the Specialist will identify, collect, assess, monitor and review documentation and encounter coding as it pertains to Clinical Coding Categories to ensure proper Hierarchical Category Conditions (HCC) assignment identifying the Risk Factors associated with the underlying conditions based on clinical documentation. PACE CNY is seeking to identify coding issues and deal with them in a timely manner while educating providers and their staff on how to prevent future issues.

Job duties specific to this position:

• Conducts initial reviews of various medical record documentation to ensure the capture of all appropriate diagnoses/procedures related to reimbursement and compliance standards.
• Routinely reviews medical record information and coding to identify appropriateness based on CMS HCC categories.
• Ensures the accuracy, completeness, specificity and appropriateness of diagnosis information.
• Verifies and ensures the accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered.
• Identifies trends/problems in medical documentation and recommends solutions to the Health Information Director/designee.
• Provides education and training regarding provider documentation via daily interaction with providers and other suitable training modalities to ensure capture of all applicable diagnoses/procedures related to reimbursement and compliance standards. Writes monthly education newsletters. Reports any trends and/or issues to the Health Information Director or designee.
• Identifies medical services provided but not adequately documented in medical record. Advises supervisor and clinicians of deficiencies to ensure accuracy, completeness and capture of maximum reimbursement.
• Prepares provider profiles on a monthly basis, prepares utilization and various statistical reports. In collaboration with Health Information Director assists in analysis as appropriate. Acts as back up person for completion of risk adjustment reports.
• Monitors compliance with procedures relevant to clinical data management. Conducts monthly audits to monitor for the accuracy of clinical coding by PACE CNY providers and outside providers via hospital bills, etc. as part of the PACE CNY’s compliance program.
• In conjunction with PACE CNY finance department, assists with claims analysis on incoming participant medical invoices. Works closely with PACE CNY finance department to ensure compliance with CMS submittal guidelines for all outside medical encounters.
• Keeps current with coding and reporting requirements and performs all necessary duties to maintain compliance. As needed, accurately completes diagnostic and procedural coding for PACE clinic providers based on clinical documentation. Ensures timely processing and submission of encounter forms in order to comply with CMS & DOH timelines. Also completes ancillary encounter diagnostic and procedural coding based on provider documentation as needed.
• Reviews questionable or denied claims from PACE CNY contracted providers. Completes medical chart review related to such claims and provides feedback to the Health Information Director.
• Keeps current on Correct Coding Initiative Edits and works with the PACE CNY finance department to ensure the adjudication system is updated appropriately.
• Updates PACE CNY and McAuliffe encounter forms yearly and as necessary as new codes become available.
• Acts as a resource for PACE CNY, the Loretto Geriatric Center Licensed Home Care Agency and various Loretto finance departments for reimbursement, compliance, and coding issues.
• Completes audits related to reimbursement coding compliance, utilization management and QA related to record maintenance and Health Information releases on an ongoing basis. Trends audit results and provides reports to the Health Information Director/Designee.
• Processes all request for medical information on prospective enrollees, tracks receipt of requested records, and provides follow-up as needed. Assists with release of information requests for current PACE CNY participants.
• Checks new enrollees’ initial visit provider diagnoses list versus diagnoses contained in old records to confirm the carryover of appropriate preexisting diagnoses. Brings discrepancies to the provider’s attention.
• Conducts in-service programs relating to health information and/or reimbursement as required.
• Provides assistance and back up help as requested to other areas of the Health Information Department.
• Performs podiatry coding for McAuliffe ancillary department, meets with providers to review coding questions; provides ongoing education regarding coding changes, expectations, and documentation requirements.
• Works with Loretto Rest Realty Finance Department regarding denied podiatry, vision, and dental claims; reviews medical records for information related denials; provides feedback to Finance Department for submission of clean claims.
• Demonstrates adherence to all compliance policies and procedures. Is responsible for promoting and fostering compliance in the workplace.
• Ensures the highest quality of care by performing responsibilities according to the highest professional standards.
• Demonstrates knowledge of PACE/D&TC Emergency Preparedness Plan and can verbalize their role during an event.

• Minimum 2–3 years of coding experience necessary. A combination of outpatient and inpatient (hospital setting) preferred.
• Certified Coding Specialist (CCS/CCS-P), Certified Procedural Coder (CPC/CPC-H) certification, or Associates Degree with RHIT credentials required.
• Proficient with ICD-10 coding; understanding of DRG systems and other reimbursement methodologies.
• Proficient with MS Office and able to learn new software rapidly. Prior experience with Electronic Medical Records highly desirable.
• Knowledge and experience in managed care environment highly desirable.
• Attention to detail and accurate input skills required.
• Strong organizational and analytical skills with ability to prioritize work.
• Strong written and verbal communication skills; strong analytical, organizational and time management skills required.
• INDPRO

An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.

Physical Requirements

Walking 10.00%

Standing 10.00%

Sitting 70.00%

Lifting 10.00% 25 lbs.

• Pay Range $22.05 - $24.37 / hour

• Excellent medical, dental, prescription and vision insurance
• Disability coverage
• Tuition Reimbursement Program
• 401(k) Retirement/Pension Plans
• Discounted Gym Membership
• Free Loretto Health Clinic Visits
• Generous Paid Time-Off Accrual
• Fun events for employees
• Convenient locations with free parking
• Employee Coaches - to help you achieve life goals
• Diaper Assistance Program
• Opportunity for career growth and movement within 19 sites!