Medical Records Tech (Coder) - OCAO - IHS

JOB SUMMARY: Medical Records Technician - Coder to provide support to management in the planning and services of the Business Office Department throughout the Oklahoma Area.

PRIMARY DUTIES:

Medical Record Analysis

• Performs comprehensive quantitative analysis by reviewing written, dictated and electronic clinical documentation records to assure the presence of all component parts of the ambulatory or inpatient visit record; including patient demographics, correct identification and validation of each part by name, health record number, signatures and dates where required, and the presence of all reports which appear to be indicated by the treatment rendered, diagnosis and procedures performed, and compliance with hospital policy, medico legal, medical necessity and regulatory requirements.
• Performs comprehensive qualitative analysis by evaluating the ambulatory or inpatient visit record for documentation consistency and adequacy. Ensures the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third-party reimbursement agencies, special screening criteria, inconsistencies or discrepancies are addressed with the appropriate healthcare provider.
• Identifies inconsistencies, discrepancies and/or trends within the medical record and discusses and formulates queries, both written and verbal, with the appropriate medical, nursing, or healthcare providers or committees, and recommends appropriate modifications to include specificity/clarification of documentation, justification of medical necessity, and adherence to the Correct Coding policy under the Correct Coding Initiative (CCI), facility policy and regulatory requirements.
• Provides ongoing education and updates to the Medical Staff and other health care providers on changing coding conventions, rules, regulations and guidelines.

Medical Record Coding

• Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology diagnostic and procedural terminology and coding guidelines to assign codes accurately' to diagnoses and procedures in accordance with official coding guidelines. Utilizes the PCC automated encoder coding books, coding conventions/guidelines, internet resources to assigns and sequences a variety of codes including but not limited to fCD-9-CM/ CPT/HCPCS/ICD-1 0-CM/ICD-10-PCS codes based on the medical record analysis. Assures the final diagnoses and procedures as documented by the provider are valid and complete. When multiple diagnoses and procedures are listed, assures the procedure is related to the proper diagnosis.
• Analyzes and abstracts information from the medical record to identify secondary complications and co-morbid conditions to assure appropriate assignment.
• Analyzes provider documentation to assure the appropriate Evaluation & Management (E&M) levels are assigned along with the correct CPT and/or HCPCS code.
• Performs audits for or in conjunction with the facility Compliance plan and Performance improvement study designs, medical records review process, and utilization review process which may include findings from provider documentation trends, coding peer reviews and reimbursement denials. Provides reports of findings, education and feedback to parties involved and may participate in committees, work groups, teams and discussions with medical, nursing and other staff regarding coding, reimbursement and documentation issues.
• Provides ongoing education and communication of updates and briefings for the medical staff, business office staff and other health care providers on changing coding conventions, rules, regulations and guidelines, as necessary to ensure documcntatiol1 and coding compliance.
• Assists in development and modification of facility coding policies and procedures and communicates with Administrative Staff, Supervisors, Administrator, Site Manager (or other hospital staff in resolving coding, abstracting procedures, RPMS and EHR problems and recommends alternate procedures.
• Maintains statistics for documentation deficiencies and assists providers in completion of incomplete and delinquent records.
• Makes the final determination the medico-legal requirements of the record are complete, accurate and reflects sufficient data to justify the diagnosis and warranted treatment.

Other

• Runs weekly error reports to ensure data is transported to the data center. Makes corrections to the error reports by validating orphaned visits in the database.
• Performs audits which may include findings from provider documentation trends, coding peer reviews, and reimbursement denials. Provides reports of findings and feedback to parties involved.
• Assists in development and modification of facility coding policies and procedures.
• Works with the healthcare providers to maintain Superbill and Pick Lists within the RPMS/EHR.
• Maintains open lines of communication with the Business Office staff on reimbursement issues as they arise and the validity of the Table Maintenance menu of RPMS.
• Maintains record confidentiality in accordance with the Privacy Act of 1974, Health Information Portability and Accountability Act (HIPAA), HITECH/Omnibus Act, Alcohol and Drug Abuse Patient Records, Freedom of Information Act and other pertinent federal regulations.
• During peak workloads, performs duties and responsibilities in the Health Information* ' Management Department that will add to its efficient operation.
• Performs other duties as assigned.

EDUCATION/CERTIFICATION:

• Background check required.

SECURITY CLEARANCE:

• Public Trust

ABOUT US: At MCSG Technologies, we believe the path to success begins by empowering our employees to do what is best for our customers. This helps create value for our customers and business partners through efficiencies and cost-effective relationships that are built on trust, while delivering on-time and within budget. Our company ethos is simple Empowered to serve our customers, our communities, our colleagues. If you would like to learn more, please visit our website at www.mcsgtech.com or find us on Glassdoor.

BENEFITS OFFERED: Medical, dental, vision, life insurance, short-term disability, long-term disability, 401(k) match, flexible spending accounts, EAP, parental leave, paid time off, holidays and more. Learn more about MCSG Technologies benefits: https://www.mcsgtech.com/benefits/.

COLORADO'S EQUAL PAY ACT: In compliance with Colorados Equal Pay for Equal Work Act; MCSG Technologies considers several factors when extending an offer, including but not limited to, the role and associated responsibilities, a candidate's work experience, education/training, and key skills.

EOE STATEMENT: We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, disability status, protected veteran status or any other characteristic protected by law.

EXECUTIVE ORDER 14042 ENSURING ADEQUATE COVID-10 SAFETY PROTOCOLS: The United States government may require that all employees, plus all contract employees performing services on behalf of the federal government, be fully vaccinated against COVID-19. In accordance with EO 14042, MCSG Technologies may require that all employees with MCSG Technologies be fully vaccinated against COVID-19.