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Clinical Reimbursement Manager |
| Mount Sinai Medical Center, Manhattan, NY |
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(Part time) |
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Job Description:
The Clinical Reimbursement Manager is responsible for performing quality reviews on medical records to validate the ICD-9-CM codes, DRG appropriateness, missed secondary diagnoses and procedures, and ensure compliance and accuracy of the MS-DRG and APR DRG. The Clinical Reimbursement Manager will continuously evaluate the quality of clinical documentation and monitor the appropriateness of physician queries with the overall goal of improving physician documentation through physician education and feedback and achieve accurate coding to support the optimal allowable reimbursement. The Clinical Reimbursement Manager works closely with the Coding Compliance Coordinator and Coding Compliance Manager to provide coding staff with feedback to assure coding uniformity, consistency and accuracy with ICD-9-CM and CPT-4 guidelines, UHDDS, sequencing guidelines, Federal and State regulations and the American Hospital Association coding guidelines and its publication Coding Clinic and AMA's publication CPT Assistant. The Clinical Reimbursement Manager works in conjunction with the Associate Director of Coding & Compliance to develop coding in-services and institutional coding policies to ensure that coding policies complement the official coding rules and guidelines.
Responsibilities and Duties:
Performs data quality reviews on inpatient records to validate the ICD-9-CM codes, MS-DRG or AP-DRG, APR-DRG, identify missed secondary diagnoses and procedures, and ensures compliance with all DRG mandates and reporting requirements.
Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and documentation improvement.
Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participates with the planning and development of educational programs directed towards improving documentation.
Creates and monitors inpatient case mix reports and APR-DRG accuracy to identify patterns, trends, and variations in the facility's frequently assigned DRG reports or specific areas impacting US News and World Report ratings. Once identified, the Clinical Reimbursement Manager evaluates the causes of the change or problems, and takes appropriate steps in collaboration with coding staff, HIM management staff, CDI leadership and the hospital administrative staff.
Demonstrates advanced knowledge about HIS standards of coding and applies to ongoing evaluation of medical record documentation in all facility care settings. To include ICD-9-CM and HCPCS coding principles.
Consistently meets established productivity targets for work assignments.
Assists with inpatient coding during staffing vacancies and high volume workflow to assure maintaining a 3 day coding turnaround time.
Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places.
Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
Assist in the review and distribution of coding related information to clinical staff, including CPT-4-CM and ICD-9-CM code changes, medical necessity policies and coding/billing information regarding new procedures and devices.
Assists in education and training of all coding team members.
Assist in continuous review and support of revenue cycle with Associate Director of Coding and Compliance.
Participate in education programs to maintain up to date coding skills.
Assist in data reporting, i.e. SPARCs, RAC, etc.
Computes, analyzes, and presents reports generated from 3M report writer for internal use and improvement initiatives.
Investigates and acts to resolve outstanding accounts appearing on the discharged not final billed and Trac reports. Communicates issues to responsible individual and/or department for prompt resolution of unbilled accounts.
Responsible for remaining current with the latest healthcare technology and coding advise through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for outpatient reimbursement and coding.
Assists Associate Director with scheduling, planning and conducting coding in-services for staff members.
Participates in the Studer service excellence five pillar programs focusing on excellence in service, quality, people, finance and growth.
Performs other duties as assigned.
Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds.
Mount Sinai Medical Center--An EEO/AA-D/V Employer
Job Qualifications:
High School Diploma or GED.
Bachelor's Degree preferred.
Registered Health Information Administrator or Registered Health Information Technician or equivalent experience preferred. Certified Coding Specialist Certification (CCS, CCS-P) required. A strong background in ICD-9-CM Classification Systems. Anatomy, Physiology, Clinical Medical and Medical Terminology is required. Minimum of 3 years experience working in an acute care hospital. Must have excellent working and current knowledge of federal and the All-Payer DRG reimbursement methodology. Must be detail oriented with good verbal, written and computer communication skills, interpersonal and customer friendly skills, ability to operate PC based software and working knowledge of Microsoft Office Suite. Ability to work under pressure with time constraints. Must be able to understand and follow written and verbal instruction. The individual must have the ability to organize multiple priorities and make independent decisions. Must demonstrate initiative and ability to work with physicians and other healthcare providers. The team member has access to patient medical information, involved in ensuring the integrity of the legal medical record and must strictly uphold patient confidentiality.
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( AllHealthcareJobs Job ID:602045 last updated on 11/21/2009)
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