Allegheny Health Network Careers

Date Posted: 2-1-17

Position Number: 55316

Location: Corporate

Allegheny Health Network is an integrated delivery network focused on preserving health care choice and providing affordable, high-quality care to the people in our communities.  With more than 14,000 employees including 7,400 health care professionals, nearly 200 primary care and specialty care practices, Allegheny Health Network includes seven hospitals in Pennsylvania with nearly 2,400 licensed beds.

Allegheny Health Network’s clinical expertise ranges from primary care to the most complex surgical procedures.  Services include cancer diagnosis and treatment, cardiovascular care, neurological and neurosurgical services, organ transplantation, orthopedic and rehabilitation services, and women’s health.

Status: Full Time

Union/ Non-union: Non-union

Job Summary: Performs all related internal, concurrent, prospective and retrospective coding audit activities. Codes and abstracts medical records to determine data quality and accuracy of coding, billing and documentation related to DRG's, APC's, CPT and HCPCS Level II code and modifier assignments, ICD diagnosis and procedure coding, DRG/APC structure according to regulatory requirements. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, training, process changes, risk reduction, optimization of reimbursement with new and current coders in accordance with coding principles and guidelines. Promotes coorperation with CDMP and compliance programs to improve documentation which supports compliant coding. Interacts with external consultants regarding billing, coding and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines.

 Job Responsibilities:

• Plans and conducts audits and reports on the documentation, coding and billing performed at AHN entities.
• Reviews, develops and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements. Provides written audit guidance.
• Participates with management in the assessment of external audit findings and responds as needed. Attends meetings and interacts with management to resolve issues and provide advice on new programs.
• Provides guidance to system entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Determine appeal action, prepare appeal letter follow up and identify education issues. 
• Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact and profitability.
• Conducts education/training presentations of final audit findings to department staff, physicians and appropriate individuals.
• Validates the ICD CM, ICD PCS, CPT and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements.
• Performs periodic claim form reviews to check code transfer accuracy from the abstracting system and the charge master. 
• Creates and monitors inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends and variations in the facilities frequently assigned DRG/APC groups.
• Once identified, evaluate the cases of the change or problems and takes appropriate steps to effect resolution.
• Provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology and disease processes as it relates to the DRG/APC and other clinical data quality management factors.
• With technical direction and assistance from management, designs and implements coder education program, continuing education programs and Medical Staff education programs.
• Establishes and monitors performance and maintains appropriate documentation thereof. 
• Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD CM ICD PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC. 
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines.
• Assures compliance with the coding guidelines and regulatory requirements.
• Performs other duties as assigned or required including performing audits and research related to special projects and providing coverage for coding manager(s). 
• Develops and implements an organizational framework for quality and safety.
• In conjunction with the Director Quality and Safety Allegheny Clinic, will develop indicators for both quality and safety to measure and improve upon.
• Monitors and analyzes data to provide information to support the quality improvement process and learning.
• Demonstrates an acute understanding of HEDIS, outcomes management and nationally recognized quality processes such as NCQA.
• Provide leadership and education around safety.
• Co-chair the multi-disciplinary Allegheny Clinic Quality and Safety team.
• Will travel frequently to various site locations throughout the Health Network.

Requirements:

Licensure/Certification/Registration: 

• Current RHIA, RHIT or CCS certification required.
• Current driver's license as travel throughout Western PA is Required
• Minimum of 5 years experience in hospital coding and/or auditing, as well as, eduction techniques and methods are required.
• In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems.
• Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective Payment System and Coding Clinic References.
• Current working knowledge of encoder, grouper, absracting and other related software.
• Strong analytical and communication skills are required.
• Minimum of 3 years experience with claims processing and data management preferred.

Preferred:

• Past auditing and strong education/training background in coding and reimbursement preferred.
• Associate's Degree preferred.