Coding and Data Management Specialist

JOB SUMMARY: Bears core responsibility for medical coding, contract management, monitoring contracted provider credentials, processing encounter data, claims adjudication and electronic health records.

JOB RESPONSIBILITIES:

• Maintains minutes of morning staff meetings, Participant Advisory Committee meetings, and other meetings as requested.
• Reviews medical records and encounters to validate diagnosis codes with oversight by the Quality Manager. 
• Maintains knowledge and serves as the administrative superuser of the electronic health record, troubleshooting issues and conducting trainings as necessary
• Acts as liaison with the vendor who maintains and revises the electronic health record.
• Enters encounters into the automated payment system used by the third party administrator.
• Processes risk adjustment and encounter data in keeping with CMS guidelines for PACE organizations.
• Seeks, obtains and maintains contracts with health and social service providers for the PACE network.
• Maintains up-to-date copies of contracts with providers in the PACE network.
• Maintains a database of transient information related to provider contracts.
• Maintains evidence of licensure and professional liability insurance coverage for contracted providers.
• Utilizes the United States Department of Health and Human Services - Office of the Inspector General – Exclusion Program to check whether contracted providers are excluded from participation in Medicare or Medicaid.  Maintains documentation of annual checks for such exclusion.
• Enrolls PACE participants in Medicare to secure payment through CMS automated system.
• Maintains, updates, and investigates Medicare issues, especially COB (coordination of benefit), MSP (Medicare as a secondary payer), and retroactive enrollment.
• Maintains registries of participants for the third-party administrator, Medicare and other agencies.
• Monitors participant enrollment in Medicare.
• Assists the Quality Manager with the creation and maintenance of databases, charts, and graphs used in the Quality Improvement program.
• Serves on the Medical Records Committee and acts as the Audit Team Lead for medical record audits. 
• Helps assemble and report information required by audit teams from Medicare and Medicaid.
• Assists staff with information management systems as needed.
• Is courteous, polite and helpful to participants, staff, and the public.
• Participates in staff meetings and in-service training sessions.
• Performs other related duties as required.
• Acts only within the scope of his or her authority as delegated by supervisor.

ESSENTIAL FUNCTIONS:

• Oral and written communication skills
• Interpersonal skills
• Computer knowledge and skills
• Basic accounting knowledge
• Organizational skills
• Problem solving skills
• Reporting knowledge and skills

SUPERVISORY RESPONSIBILITIES:        None

QUALIFICATIONS:   

High school graduate or equivalent.

Bachelor’s degree preferred.

Pleasant personality with good telephone etiquette.  

Ability to work under pressure and handle conflicting demands. 

Expertise with Excel and Word software required.

Capacity to learn, use and train users on additional computer software systems.    

Experience in data management and medical records.

Experience in medical coding preferred.  

Experience in health care, social services or public administration preferred. 

Ability to interact calmly with people in difficult and unusual situations.

Medically cleared for communicable diseases with up-to-date immunizations before participant contact.  

Criminal history records check at hire. 

Drug screen at hire.