The Claim Edit Specialist (remote) is responsible for an advanced level of analyzing, reviewing and resolving coding and charge edits for medical necessity or other coding- or charge-specific claim issue. In an effort to optimize reimbursement and reduce denials, the Claims Edit Specialist actively seeks opportunities to positively impact revenue and coding workflows and metrics, utilizing experience to identify process improvement needs and implement best practices as well as gather relevant trends and communicate findings to management and make recommendations for education and process improvement.
This role works independently with other departments and supports the importance of accurate, complete and consistent coding practices for the production of quality healthcare data.
RESPONSIBILITIES:
- Requires the ability to read and effectively analyze a hospital medical record as it relates to clinical documentation and diagnostic/procedural coding of the services provided.
- Requires advanced current and continued knowledge of ICD-10, CPT, PCS and HCPCS guidelines, APC and MS-DRG groupers, and coding terminology as it relates to facility coding.
- Requires a solid understanding of third-party hospital payer requirements, guidelines, government regulations and coding compliance.
- Requires the ability to identify through investigation and analysis, underlying causes and contributing factors to areas of weakness, making appropriate recommendations.
- Requires comprehensive knowledge of current regulatory requirements related to Medicare and Medicaid billing including coding and documentation standards and guidelines.
- Requires current and continued knowledge and comprehensive understanding of claim filing and coding principles. Familiarity with the Kentucky regulatory environment is strongly preferred.
- Extensive working knowledge of NCD/LCDs, AHA Coding Clinics for ICD-10-CM/PCS and HCPCS, CPT Assistant and other regulatory guidance with demonstrated ability to research in each platform.
- Experience 3M Coding & Reimbursement software required.
- Exceptional communication (verbal and written) and interpersonal communication skills; ability to interact with all levels of the organization effectively.
- Must possess the ability to work remotely with minimal supervision.
- Ability to maintain professional ethics and standards at all times.
- Possess high level of organization skills.
- Excellent computer skills and experience with Microsoft Office applications.
Required Skills
Licensure/Certification/Education:
- CCS, RHIT, RHIA, or CPC required.
- Associate or Bachelor’s Degree in health care or business equivalent is preferred.
Required Experience
Minimum Work Experience :
- Minimum 7 years of facility inpatient and outpatient coding experience required.
- Minimum 2 years’ experience as claims edit or denials specialist preferred.
- Minimum 2 years’ experience working in a remote setting required.