• Works with medical providers or medical record staff to ensure that correct diagnosis/procedures are reported to third-party insurance carriers.
• Regularly work with patient navigators to ensure correct patient/ insurance information is obtained.
• Reviews patient charts for all required documentation to support the medical provider's specific coding of the visit.
• Perform reviews, audits, and the coding of medical records to ensure that appropriate diagnostic codes and modifiers are used in accordance with Generally Accepted Medical Coding Guidelines and both ICD-10 guidelines, and CPT codes.
• Monitors claims for missing information, authorization/control numbers.

• Must provide excellent customer service skills and professional telephone conduct with patients and insurance company representatives.

• Maintains confidentiality of all information.
• Completes work within authorized time to assure compliance with departmental standards.
• Keeps updated on third-party billing requirements and changes for insurance types within their area of responsibility.
• Demonstrates knowledge of, and supports, mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.
• Responsible for reviewing medical records to abstract ICD-10 codes that map to HCCs from a variety of different CMS Hierarchy models including Medicare Advantage, PACE, Commercial, and Medicaid CDPS models. In addition to abstracting diagnosis codes, the Clinical Review Specialist also
• Performs other duties as required.

Experience

• •Successful completion of high school or commercial coursework, including math, bookkeeping, and business. Post-high school courses in insurance billing, data processing, and medical terminology are preferred. • 2+ years’ experience in medical risk adjustment / HCC coding •Nationally certified CRC coder in good standing through AAPC or AHIMA
• Ability to bill third-party insurance for facility and professional claims by hard copy and electronically is preferred. Knowledge of third-party billing requirements is also preferred.
• •Excellent knowledge and understanding of ICD-10, CPT & HCPCS coding and efficient use of modifiers. •Demonstrated high level of quality accuracy and productivity in clinical coding work •Adherence to official coding guidelines (including coding clinics, CMS, client specific guidelines and other regulatory compliance guidelines and mandates)
• •Excellent written and verbal communication skills with the ability to understand and explain complex information •Strong knowledge of medical terminology and anatomy and physiology •Skills in organization and time management •Comfortable with computers and technology •Must be able to work in a fast-paced environment •Ability to manage and meet deadlines, adapt to changing priorities, flexible and open to new ideas

Education

• High School or better

Licenses & Certifications

• CRC Coder