Job Description
Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.
Summary:
The Physician Practice Documentation Review Specialist provides quality review and analysis of a wide range of patient medical records and ensures the accuracy of coding and billing of professional services. The Specialist is responsible for reviewing (auditing) medical records to ensure proper billing of professional claims by comparison of provider or coder chosen CPT, HCPCS, HCC, and ICD-10 codes to the providers' documentation to substantiate the appropriate code level, code choice, or necessity of the service.
Essential Duties and Responsibilities:
* Based on assignment, the Specialist audits random samplings based on productivity of evaluation and management, procedural, and ancillary services to validate the accuracy of documentation and coding within the medical record to ensure compliance with CHS policy and Medicare, Medicaid and other payer requirements.
* The Specialist verifies medical record standards such as signature and attestation requirements, authorizations, waivers/ABNs, and consents that pose risk to reimbursement or regulatory requirements.
* Using the audit management software, or other designated method, prepare a comprehensive report based on the findings of the documentation and coding review.
* Works within the CHS compliance plan to notify the Compliance Department and Physician Practice Leaders of educational needs of providers and staff regarding coding and documentation. Able to interact confidently with providers, staff, corporate CHS management, and/or other CHS affiliated personnel.
* Serves as a resource and liaison in the organization for all coding-related topics, issues and questions.
* Remains current on all changes in National and Local Coverage Determinations and legislative regulations that impact coding, documentation, and compliance.
* Maintains strict confidentiality of provider information, patient data as well as financial and billing data.
* Must submit samples of work to their supervisor for Quality Assurance on a bi-annual basis and maintain a score of 95% or better accuracy.
* Assist in developing and maintaining educational materials needed to achieve compliance with regulations.
* Assist with special projects as assigned by their supervisor or the Senior Director, Physician Practice Compliance.
Minimum Qualifications:
* Required Education: High School Diploma and/or GED required
* Preferred Education: AA/AS or higher, or Technical Diploma equivalent
* Required Experience: Minimum 5 years experience in CPT, ICD 10, and HCPCS coding/auditing and reimbursement issues for physician professional services. Requires extensive knowledge of CPT, HCPCS, ICD 10 CM coding, medical terminology and the AMA's and CMS' 1995, 1997, and 2023 E&M Documentation Guidelines.
* Preferred Experience: 7 years experience in CPT, ICD 10, and HCPCS auditing physician professional services. Requires extensive knowledge of CPT, HCPCS, ICD 10 CM coding, medical terminology and the AMA's and CMS 1995, 1997, and 2023 E&M Documentation Guidelines.
* Required License/Registration/Certification: CPC or CCS-P
* Preferred License/Registration/Certification: CHC, CPMA, or CPCO
* Computer Skills Required: Knowledge of Microsoft Word and Excel, Google products, Encoder software, and Electronic Health Records systems.
* Preferred Professional Fee experience
Physical Demands:
In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:
* The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.
* The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.
* The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work.
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