Job Description
The Revenue Integrity Specialist (RIS) is responsible for conducting medical record compliance audits for documentation, billing, and compliance with state and federal requirements for professional fee coding. The RIS shares audit results with providers and conducts ongoing education. In addition, the RIS is responsible for reviewing all external coding audits and responding to audit findings.
Essential Duties & Responsibilities:
- Audits medical record documentation for accurate assignment of diagnosis, current procedural terminology and evaluation and management codes. Researches coding and reimbursement issues and reports findings to management, clients and others.
- Provides ongoing education to clients on documentation requirements for accurate code assignments. Works with client management for any training-related questions.
- Performs internal quality assessment reviews on professional coding to ensure compliance with national coding guidelines and client’s policies for complete, accurate and consistent coding that results in appropriate reimbursement and data integrity.
- Communicates both internal and external audit results and provides education to clients as required. In addition, provides summary audit results to the Coding Manager, DHIM, and others as outlined by coding review policy.
- Collaborates with Clinical Documentation Improvement lead (if applicable) to identify opportunities for training and education needs.
- Assists in appeals process resulting from third party payor reviews.
- Reviews, researches and prepares response(s) to all third party payor external coding denials within the time frame required by the third party payor.
- Responsible for assuring all required coding and data corrections from any retrospective review findings are completed and submitted to the Patient Financial Services Department as required by the facility.
- Maintains coding accuracy statistics for each provider.
- Maintains coding accuracy rate of at least 95% and meets or exceeds productivity standards.
- Adheres to Official Coding Guidelines, CMS policies and regulations and client’s policies and procedures.
- Keeps current with all CPT/HCPCS and ICD-10 coding principles, requirements and coding reference guidelines as well as Hospital Acquired Condition diagnoses, Patient Safety Initiatives and Office of Inspector General’s worklist.
- Maintains strict physician and patient confidentiality.
- Reviews materials, completes all required clientpolicy training documents and passes required tests.
- Provides coverage for coding positions as needed.
- Supports Compliance Program by demonstrating adherence to all compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information.
Requirements:
- High school diploma or GED.
- 3+ years of professional fee coding and auditing experience.
- Certification from AHIMA or AAPC. Must hold at least one of the following certifications: RHIA,RHIT, CCS, CCS-P, CPC, or COC.
- Knowledge of medical terminology, anatomy and physiology, laboratory test and results, disease processes and pharmaceuticals required.
- Thorough understanding of hospital billing, chart reviews and coding, payer contracts and reimbursement rates, as well as other revenue cycle functions.
- Knowledge and ability to investigate and resolve denials in a professional fee setting.
- Knowledge and proficient in the application of ICD-10-CM, and HCPCS/CPT code assignment.
- Knowledge of LCD (Local Code Determinations, NCD (National Code Determinations), CCI (Correct Coding Initiatives).
- Proficient with computer systems, encoders, Computer Assisted Coding software, and electronic health records.
- Proficient in using Microsoft Word, Excel and PowerPoint applications as well as proficient in using web based communication applications.
- Demonstrated ability to communicate, engage and influence stakeholders to improved outcomes.
- Demonstrated ability to clearly present sensitive information to stakeholders.
- Experience working under pressure within a changing environment
- Must be willing to work onsite in Ortigas, Pasig City.
Preferred Skills:
- CPMA.
