As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.
The Auditor will participate in and assist with regular feedback to CRC teams, and operational departments. As a subject matter expert, the Auditor will mentor and advise in the various areas of quality as required.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Understands, interprets and applies coding guidelines for coding quality audits of denied claims. Determines coding accuracy of all documented diagnoses and procedures. Reviews claims to validate submitted codes and abstracted data, including, but not limited to, ICD-10-CM/PCS codes, MS-DRGs, APR-DRGs, CPTâ��s, APCâ��s, and discharge disposition which all impact facility reimbursement and RVUs which impact pro-fee reimbursement
Creates clear and accurate audit findings and recommendations via written appeals and audit reports that will be used to support coding and documentation with commercial and government payors, advising and educating Coders, Billers, Auditors, Managers, and Directors throughout the organization
Identifies documentation issues that impact coding accuracy. Clearly communicates verbally and in written reports or summaries) opportunities for documentation improvement related to coding issues
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and CPT coding. Completes online education courses and attends mandatory coding workshops and/or seminars (IPPS and OPPS, ICD-10-CM and CPT updates for inpatient, outpatient, and Pro-Fee coding. Reviews AHA and CPT quarterly coding update publications. Attends all internal conference call for Quarterly Coding Updates.
Responsible for submitting telecommuting expenses timely.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals.
Possesses excellent written and verbal communication skills
Possesses professional letter writing skills
Ability to consistently and accurately audit complex coding of inpatient, outpatient, and pro-fee encounters as required
Ability to create clear and concise audit reports and appeal documents while maintaining productivity standards
Must successfully pass pre-hire coding assessment
Expert level knowledge of medical terminology, ICD-10-CM/PCS and CPT coding guidelines and methodologies
Expert level knowledge of disease pathophysiology and drug utilization
Expert level knowledge of MS-DRG, APR-DRG, APC, and RVU classification and reimbursement structures
Expert level knowledge of APC, OCE, NCCI classification and reimbursement structures
Expert level knowledge of HACs, PSIs, and HCCS
Must be detail oriented and have the ability to work independently and in team setting
Moderate skills in MS Excel and PowerPoint, MS Office
Must display excellent interpersonal skills
Ability to demonstrate initiative and discipline in time management and assignment completion
Ability to research difficult coding and documentation issues and follow through to resolution
Ability to manage time effectively and prioritize assignment and projects
Ability to work in a virtual setting under minimal supervision.
Ability to conduct research regarding State/Federal guidelines and applicable regulatory processes related to Government Audit processes.
Maintains coding credentials and completes required continuing education
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
Associates degree in relevant field preferred or combination of equivalent of education and experience
Five (5) years coding experience including but not limited to hospital inpatient, outpatient, and/or pro-fee encounters
Five (5) years of experience in coding quality audit work including but not limited to hospital inpatient, outpatient, and Pro-Fee encounters
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to lift 15-30lbs
Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
Interaction with facility HIM.
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.