jenniferfishrhia

 Performs complex review of physician clinical documentation on inpatient and outpatient medical records.  Performs quality analysis to determine accuracy of diagnostic and procedural coding, the correct interpretation and – application of official coding guidelines and rules, and assignment of appropriate codes.  Determines correct payment methodology and reimbursement.  Develops case-specific written rationale to substantiate and communicate findings to hospital, provider, medical director, and peer review team.  Conducts coding re-review for decisions that are based on coding convention and sequencing guidelines, not requiring medical review.  Identifies clinical questions and refers cases to Medical Director.  Responds to providers for resolution of appeals.  Mentors and oversees Coding Quality Coordinators I and II and assesses their ongoing educational needs.  Reviews updates to Coding Clinics, coding newsletters, and other professional resources to maintain up-to-date knowledge.  Participates in ongoing in-service programs for coding related or clinical education.  Identifies and interprets patterns of possible fraud or abuse and refers to appropriate party for further evaluation and corrective action.  Conducts periodic peer review.  Coordinates and leads Coding Roundtable meetings and continuing education presentations.  Analyzes case selection reports to identify cases for complex review.  Delivers coding-related in-service training for associates from other departments.  Serves as expert resource on coding and payment methodologies for other departments and subcontractors.