Coder / Utilization Review Specialist
Location : Potential to be fully remote post training, if desired.
Job Summary
The primary job function of the Coder / Utilization Review Specialist is to complete daily coding of inpatient, outpatient, and professional claims. The ideal candidate is expected to have knowledge of ICD-10-CM and CPT coding rules and regulations to assist in daily coding and releasing of claims. The Coder / Utilization Review Specialist will assist with maintaining complete and accurate medical records and provide for their safekeeping and availability. The position will also be responsible for conferring with medical personnel and reviewing medical records for established criteria in accordance with all functions necessary for utilization review purposes. As part of the job function, the Coder / Utilization Review Specialist will need to access patient health information for treatment, hospital operations, and payment purposes. See hospital / department policy and procedure for access granted for this job function.
Education
- High School Diploma or GED required
- Associate Degree in HIM, Nursing, or other Allied Health Program preferred
Experience
2-4 years working in Health Information or Clinical Setting required
Certificate, Licenses, Registrations
One or more of the following RHIA, RHIT, CCS, CCS-P, LPN other relevant certifications or licenses may be considered
Primary Job Duties
Adheres to Brodstone Healthcare's Mission, Vision and Values.Adheres to Brodstone Healthcare's Standards of Behavior.Ability to work with others in a team environment, ability to accept direction from supervisors, ability to follow work rules and procedures and ability to accept constructive criticism.Should be familiar with the functions of the 3M Encoder as needed to perform job.Ability to learn and adapt to new technology as it relates to HIM and electronic medical records practices and procedures. Should be able to navigate the electronic medical record to perform job functions.Completes operation report log daily and attaches pathology reports monthly.Checks computer daily for unapproved electronic documents and makes corrections accordingly.Faxes reports as needed.Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards as approved by the Utilization Review Committee.Compares outpatient and inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.Report and maintain documentation regarding patient continued hospitalization.Abstracts data from records and maintains statistics.Reviews the patient record at minimum every third day utilizing the criteria for severity of illness, intensity of service and discharge screens as approved by the Utilization Review Committee.Assists with the discharge planning process by referring patients, as designated in the Utilization Review Plan, as early in admission as possible to the Case Management Designee.Maintains a file of Patient Review worksheets.Reviews patient charts concurrently and after discharge for documentation and possible quality issues.Reviews all outpatient and inpatient admissions for proper level of care and length of stay and confers with medical and nursing personnel to determine proper level of care.Refers patients to the Case Management Department to obtain maximum third party payer benefits as appropriate.Works with healthcare providers on the patient's behalf to obtain prior authorizations for insurance coverage for various healthcare procedures and treatments as ordered.Consistently supports the Compliance Program and participates in ongoing monitoring of activities with respect to compliance related issues.Responsible for retention of records for the program in compliance with policies of the hospital.Resolve errors or issues with providers.Audit medical record data to ensure compliance and justify treatment or length of stay.Interview or correspond with providers to correct errors or omissions and to investigate questionable claims.Attends and participates in departmental meetings / in-services, Brodstone Healthcare quality improvement program, etc.Performs other duties as assigned.
