[Hiring] CPMA Educator & Auditor @Presbyterian Healthcare Services

Role Description

With minimal supervision directly supports the following responsibilities of the Coding and documentation quality assurance (CDQA) team:

• Implementation of and compliance to enterprise-wide and department coding policies and procedures for PHS.
• Compliance to all external regulatory agency coding rules and regulations.
• Demonstrates high-level of proficiency in performing and/or managing on-site internal audits or reviews to assess compliance/quality monitoring performed by PHS/PMG departments.
• Serves as a resource on documentation, coding, billing, and coding compliance questions.
• Works on special coding compliance related projects, develops and presents educational programs, disseminates information to PHS/PMG departments, and develops educational tools used to maintain compliance with regulations.
• Provides support via auditing and training the enterprise-wide corrective action plans for coding, audit, physician and clinician personnel identified as low performers.
• Performs medical record and billing reviews of denied and appealed claims and takes appropriate action to ensure accurate payment of claims.
• Coordinates review and tracking of appealed claims including the communication process with affected payers.
• Researches and interprets all regulatory agency regulations.

Responsibilities

• Liaison to the Manager, Information Services, Finance/Patient Financial Services, all hospitals, all PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance, and all ancillary departments in addressing functional coding, auditing, compliance and training issues and problems.
• Interacts with all levels of management responsible for maintaining accurate, complete and timely documentation in either electronic or hard copy form.
• Must be able to adapt to frequently changing work priorities and schedules.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area.
• Researches coding, billing and charging compliance issues, recommends and implements corrective action plans that assure compliance with regulatory agencies where appropriate.
• Identifies risks, develops and follows up on action plans, identifies lost revenue opportunities and any overpayments due to errors in coding and/or documentation, and provides compliance education.
• Assists in the creation of the CDQA Annual Audit Work-plan by utilizing the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, as well as internal and external risk assessments.
• Regularly exercises independent judgment in determining the reliability of data reviewed; recommends changes in existing practices to gain or maintain compliant behavior.
• Keeps actively informed on the business climate of the healthcare industry.
• Responds to inquiries and requests daily regarding coding and auditing issues and problems and ad-hoc analysis for all PHS management.
• Maintains up-to-date working knowledge of all PHS coding and auditing IT applications.
• Gathers and analyzes information and provides recommendations to address and resolve business issues for a specific business group.
• Conducts training classes in areas of coding, documentation and compliance for PHS/PMG personnel.
• Conducts systematic focused internal audits via medical record and charge ticket review to ensure correct coding, billing and charging as a member of the CDQA audit team.
• Analyzes and summarizes data from medical record and account audits and communicates results and findings to management and compliance.
• Develops new methods and processes to improve coding efficiency and effectiveness.
• Researches and investigates external and internal customer concerns regarding patient care and/or billing of patient care.
• Ensures that coding functions are performed in accordance with established quality and performance standards by monitoring system-generated reports and quality audits.
• Working hours may vary based on projects assigned.
• Must be able to travel to all of the PHS/PMG sites (including overnight). Travel varies at certain times based on assignments.

Qualifications

• High school diploma/GED required.
• Must possess at least one of the following license/certifications: RHIT, RHIA, CPC, CCS.
• A minimum of three (3) years experience in coding and/or auditing required; audit experience preferred.
• Excellent written and verbal communication skills.
• Detail and results oriented.
• Ability to work independently and make independent decisions.
• Medical terminology, ICD-9, CPT-4 and HCPCS knowledge required.
• Must have a proficient knowledge of Medicare, Medicaid, and other third party payer documentation, coding, and billing regulations for service lines(s) assigned.
• Must possess excellent organizational and planning skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously.
• Must possess computer skills, especially with Microsoft Word, PowerPoint, and Excel applications.
• Must be able to use the internet and other resource applications for research purposes and to provide documentation that supports regulations quoted in audits.
• Must possess strong written and verbal communication skills in order to communicate in clear, concise terms to management at all levels.
• Must possess a personal presence of a highly qualified professional characterized by a sense of honesty, integrity, and the ability to inspire and motivate others.

Benefits

• Comprehensive benefits package including medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Employee Wellness rewards program designed to provide engaging opportunities to enhance health and activate well-being.

Company Description

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

• Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.