ED Coding Validator - REMOTE

Exemption Status:

Schedule Details:

Scheduled Hours:

Shift:

Hours:

Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Major Responsibilities:

1. Performs focused account and Coder quality reviews on inpatient and outpatient records to validate the DRG and current editions of ICD-CM, ICD-PCS, and CPT code assignment as well as missed secondary diagnoses or procedures which may impact the Severity of Illness (SOI) and Risk of Mortality (ROM).
2. Ensures compliance with all DRG, outpatient coding, and charging mandates as well as reporting requirements.
3. Validates the DRG and current editions of ICD-CM, ICD-PCS, and CPT code assignment to ensure consistency and efficiency in the processing, data collection, and quality reporting associated with inpatient and outpatient claims.
4. Demonstrates competency in the use of computer applications, DRG grouper software, as well as all coding and abstracting software currently used in HIM.
5. Runs daily reports to ensure all focused account reviews are worked to prevent the unnecessary holding of accounts prior to billing. Informs the Manager of Coding-HIM when backlog situations arise and necessary documents are either incorrect or not received in a timely manner.
6. Provides feedback on Coder quality reviews to the Manager of Coding-HIM, Supervisor of Inpatient Coding, Manager of Emergency Department (ED) Coding, and Manager of Radiology Coding based on the Coding Audit and Performance Management policy and procedure.
7. Creates and monitors Case Mix Index (CMI) reports and accuracy of the top 25 assigned DRGs to identify patterns, trends, and variations.
8. Creates and monitors outpatient reports and accuracy of top 25 assigned principle diagnoses to identify patterns, trends, and variations in the organization's frequently assigned principle diagnoses, evaluation and management codes, modifiers, and CPT procedure changes.
9. Evaluates the root cause of any identified trends or possible problem areas. Reports variances to the Manager of Coding-HIM, Manager of ED Coding, and Manager of Radiology Coding.
10. Acts as a point person for Coding staff on questions or concerns related to ICD-CM (current edition), DRG, Evaluation and Management (E/M) code assignment as well as procedural coding and the retrospective query process.
11. Maintains direct and ongoing communications with Coding personnel to maximize overall effectiveness and efficiency of Coding operations.
12. Informs Manager(s) of any coding irregularities or trends contrary to policies / procedures and communicates with appropriate staff if necessary.
13. Assists the Manager of Coding-HIM in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
14. Assists the Manager of Coding-HIM in meeting department / unit goals and ensuring compliance with regulatory agencies such as Joint Commission, DPH, etc.
15. Works closely with the Retrospective CDIS Nurse and Clinical Documentation Improvement (CDI) Program team to continuously monitor the quality of clinical documentation to identify incomplete or inconsistent documentation in addition to any changes in DRG assignment and payment.
16. Monitors retrospective queries for appropriateness and may provide Coder feedback. Informs the Manager of Coding-HIM of any identified concerns.
17. Collaborates with the Manager of Coding-HIM as the primary department resource for the dissemination of DRG interpretations.
18. Collaborates with the Coding Educator to provide ongoing education to the Coding staff, Providers, and other clinicians to ensure appropriate assignment of current edition of ICD-CM, DRGs, E/M codes as well as modifiers and CPT procedure changes.
19. Collaborates with the Coding Educator to incorporate improvement efforts into coding in-services throughout the year.
20. Assists the Manager of Coding-HIM in preparing productivity reports and participates in the department's total quality management studies.
21. Maintains DRG and coding accuracy rate of not less than 95% for optimal reimbursement as well as department productivity standards as outlined in department policies.
22. Attends required training classes and coding in-services each year to stay abreast of new regulations and coding guidelines.
23. Participates in improvement efforts and documentation training for medical and clinical staff as it relates to coding practices and guidelines.
24. Monitors Medicare and other DRG payer bulletins and manuals. Reviews current Office of Inspector General (OIG) work plans for DRG risk areas.
25. Keeps current with all coding updates and information related to correct coding.

Standard Staffing Level Responsibilities:

1. Complies with established departmental policies, procedures and objectives.
2. Attends variety of meetings, conferences, seminars as required or directed.
3. Demonstrates use of Quality Improvement in daily operations.
4. Complies with all health and safety regulations and requirements.
5. Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.
6. Maintains, regular, reliable, and predictable attendance.
7. Performs other similar and related duties as required or directed.

All responsibilities are essential job functions.

II. Position Qualifications:

License/Certification/Education:
Required:
1. Bachelor's degree in Business or Health Care Administration.
2. Certification as a Certified Coding Specialist (CCS).

Preferred:
1. Certification as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).

Experience/Skills:
Required:
1. Minimum of five (5) years of experience coding in a large, teaching, acute tertiary care setting with demonstrated coding expertise.
2. Extensive knowledge of current editions of DRGs, ICD-CM, ICD-PCS, and CPT coding systems.
3. Through knowledge of third-party payer requirements as well as federal and state guidelines and regulations pertaining to coding and billing practices.
4. General knowledge of hospital information systems as well as extensive knowledge of computer systems / applications used in HIM.
5. General knowledge of the retrospective CDI query process as well as guidelines for achieving a compliant query and associated compliance concerns.
6. Excellent customer service skills with the ability to communicate efficiently.
7. Exceptional organizational skills with attention to detail.
8. Ability to lead, organize, and support the work of less senior Coders is a primary function of this position.
9. Ability to work independently within established guidelines.
10. Excellent oral and written communication skills required.
11. Ability to motivate, train and teach individuals; demonstrating skills in interpersonal relationships and in oral and written communication.
12. Ability to organize and coordinate multiple functions and tasks.
13. Ability to problem solve, organize, and prioritize workload to meet productivity benchmarks.
14. Ability to withstand significant level of on-going pressure, and ability to deal with individuals with tact, discretion and diplomacy.

Preferred:
1. Coding review experience in DRG assignment, and current editions of ICD-CM, ICD-PCS and CPT coding with previous claims processing and data management responsibility.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.

III. Physical Demands and Environmental Conditions:

Work is considered sedentary. Position requires work indoors in a normal office environment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.