Nature of Duties:

Primary responsibility is to review the medical record, obtain indications for services provided and perform accurate coding to the highest level possible. Complete superbill documentation and forward to the billing department. Educate and communicate to their providers, team leader, and/or Compliance Department when there is a lack of proper indications for services.

Qualifications:

1. High school diploma

2. LPN and/or CPC or Coding experience, preferred

3. Basic Life Support (BLS) preferred

4. Basic computer knowledge

6. Good Communication Skills

Specific Duties:

1. Review the medical record and the services provided to assure all services were charged and priced properly. Utilize nursing knowledge and available resources to code services to the highest level by selecting the most appropriate ICD-10code. Be alert to the following areas: dates of service need for signatures, accurate and complete documentation, etc. to complete the coding process and reconciliation of charges when needed. Code bloodwork with proper indications and ICD-10 codes.

2. Assess appropriate utilization of services and communicate to the Director of Coding and/or Practice Administrator & physician when services lack appropriate indications. Verify proper referring physician and/or the physician supervising tests. Assist the pre-certification personnel by providing coding information and the billing/denial process by reviewing coding practices and making necessary changes.

3. Answer questions regarding coding and proper indication use for nurses, technicians and/or physicians. Assist in the education of the other coders and answer their questions. Research computer for appropriate billing and coding information on patient accounts when needed. Communicate the need for CPT’s to the billing/coding teams and/or Director of Coding to place into the computer.

4. Answer questions proposed by the billing department regarding coding. Assign and submit charges and codes in a timely manner especially at the end of month to assure timely billing of services. Run and work assigned clinic’s unbilled report timely, at least monthly.

5. Assist the Correspondence Department; work cooperatively with the Clinical Data/Correspondence Team Leader and/or staff of the correspondence department. Coordinate the referral tracking process and collect clinical information on patients through the review of the clinic medical record, hospital record and/or communication with the physicians, staff, patients and/or family members. Communicate relevant information and network clinical information to the physicians, staff, patient and/or family members. Report any problems identified through clinical record review to the team leader.

6. Performs other related duties as assigned and serves in whatever other capacity deemed necessary for successful completion of the mission and goals of the organization and in concordance with its patient philosophy.

Standards of Performance:

1. Keeps work area neat and organized. Reports safety issues to team leader immediately.

2. Works efficiently and manages time wisely. Assist other employees when all duties are complete.

3. Communicates any problems, difficulties or concerns regarding job duties to the team leader.

4. Performs all duties without significant error occurring with any regularity.

5. Meets all deadlines and timeframes for completion of assignments.

6. Represents the organization in a professional manner at all times. Demonstrates acceptable ability to interact with physicians, staff (“internal customers”) and “external customers” (patients, family members, insurance companies, home health etc.) on a professional level at all times. Exhibits good communication skills with physicians, patients, team leaders, and co-workers at all times.

7. Exhibits a harmonious relationship with other employees in order to accomplish the duties and responsibilities of the position. While perfect harmonious relationships with all employees is sometimes not achievable, not more than an occasional complaint should be received by the team leader about the incumbent of this position.

8. The employee shall work and relate cooperatively with all other employees (internal customers) of the organization to assure optimum care for the patients of the organization and to achieve standards of care set forth by the medical staff.

9. Adheres to the Compliance Plan as it pertains to the above specific job duties. Uses best efforts to maintain compliance by following the Corporate Compliance Plan, attending compliance education, following medical documentation guidelines, and communicating concerns regarding compliance issues.

10. Performs accurate and complete documentation in the patient’s medical record, when applicable. This includes documentation in both the paper record and the electronic medical record (EMR).

11. Work with the electronic medical record (EMR) staff to maintain quality and work towards future EMR development.

12. Maintains patient confidentiality according to the HIPAA standards of privacy and security.