Coding Compliance Specialist researches and develops the pre-certification insurance policy standards and criteria used by case management and utilization reviewers that will ensure that requested medical services are appropriate and medically necessary. Collaborates with medical professionals to resolve questions about policy development and standards. Being a Coding Compliance Specialist assigns correct ICD, CPT, or other coding assignments for medical procedures that support policy standards in claims systems. Provides expertise and solutions to users regarding the appropriate coding for claims. Additionally, Coding Compliance Specialist has broad knowledge of medical coding systems. May require an associate degree in healthcare administration, a related field, or equivalent. Requires AAPC Certified Professional Coder (CPC). May alternatively require Certified Coding Specialist (CCS) certification. Typically reports to a manager. The Coding Compliance Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Coding Compliance Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
Clinical Coding Specialist III
Thoroughly reviews the entire medical record to specifically and accurately code those diagnoses and procedures that were treated or affected patient’s plan of care. Verifies that the record contains appropriate documentation to justify the codes assigned. Assists with auditing medical records for quality of coding and to ensure appropriate reimbursement and reports findings to Coding Coordinator. Will be able to serve as backup for coding, billing, abstracting, and/or auditing of Outpatient and ED records. This specialist will be responsible for remaining current on all ICD and CPT coding changes as well as payer specific requirements and regulations.
Qualifications
The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this position.
Education/formal training/licensure/certification/experience:
· Degree in HIM. RHIA or RHIT preferred; CCS required.
· 4 years coding experience in hospital setting (at least 2 years inpatient)
· Experience in DRG validation or chart auditing preferred
· Thorough understanding and experience in both ICD-10 and CPT 4 required
· Minimum of 90% score on competency assessment
· Must be consistently exceeding standards of Level II and/or score minimum of 90% on competency sampling
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