Coding Quality Assur Spec I

 
Position: Coding Quality Assur Spec I

Job ID: 160089

Department: UM CLAIMS APPEALS

Talent Area: Clerical

Full/Part Time: Full-Time

Regular/Temporary: Regular

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org. Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Coding Quality Assurance Specialist -- someone who works well in a fast-paced setting. In this position, you will audit the accuracy of the provider assigned ICD-10-CM, CPT and HCPCS codes to a variety of provider types to include but not limited to ambulatory, emergency center, observation, and day surgery records for the purposes of ascertaining the accuracy of the physicians' E/M and procedures coding to their documentation. The Specialist also completes the auditing reporting tool and provide this feedback to the claims examiners for accurate claims appeal processing.



Responsibilities :

  • Reviews documentation in records to appropriately assign ICD-10-CM, PCS, and CPT codes
  • Utilizes the encoder or coding books to correctly assign all appropriate ICD-10-CM, ICD-10-PCS, and CPT codes for diagnosis and procedures
  • Reviews accuracy of sequenced diagnosis and procedures to generate appropriate DRGs for billing in accordance with the Coding Guidelines based on the type of coding
  • Utilizes available resources for accuracy of code(s) assigned on appealed claim as necessary (e.g. Diagnostic Imaging system, Lab system, Emergency Center system, Cardiac Cath system, Epic, and coding reference books)
  • Identifies claims edit problems
  • Identifies and reports patterns of inappropriate coding practices to include but not limited to unsupported charges, uncoded charges, missing or inappropriate use of modifiers, physician billing for other Medicaid providers
  • Attends and participates in coding education sessions
  • Obtains required number of CEUs for current certification and completes required education


Qualifications:

  • Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption
  • High school diploma or GED required
  • CCA, CCS, CCS-P, RHIA or RHIT from American Health Information Management required
  • CIPC, COC, COC-A, CPC, CPC-A, or CRC from the American Academy of Professional Coder required
  • 1 year experience as a coder preferred


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