Ephraim McDowell Health

JOB SUMMARY:

Leads, coordinates and monitors denial and audit activities for Ephraim McDowell Health. Conducts oversight on all third-party auditing functions. Tracks the status of all activities throughout systems. Analyzes and prepares administrative reports. Responsible for coding injection and infusion accounts for Ephraim McDowell Regional Medical Center, Fort Logan, and James B. Haggin. Responsible for numerous essential office functions. Must exhibit the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service, and Trust).

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES

1. Assigns the appropriate charge/CPT code for injections and infusions.
2. Stays abreast with coding regulations, specifically related to injection and infusion coding.
3. Identifies targeted “hot topic” audits. Educates the affected areas on what is being audited and what needs to be done to ensure appropriate documentation, payment, etc.
4. Reviews, understands, presents, and applies information learned from PEPPER reports distributed quarterly.
5. Enters and maintains denial information. Reports on trends of denials.
6. Meets deadlines for appeal process.
7. Prepares medical record requests for medical necessity audits.
8. Reviews and educates appropriate parties on experimental/investigational denials.
9. Actively participates and is a member of the denial committee. Reviews trends and educates appropriate parties of denials.
10. Works closely with coding and CDI staff to ensure that DRG appeal letters are complete, accurate, and thorough.
11. Works with the CMO to ensure that appropriate appeal letters are sent to insurance companies regarding DRG and clinical denials.
12. Reports dashboard of DRG denial amounts and trends to coding and CDI staff monthly.
13. Coordinates audits with third party companies requesting access or to come on site for medical record review.
14. Responsible for training additional staff on injections and infusions as needed.
15. Abides by the Standards of Ethical coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
16. Maintains positive relationships with other departments and the Organization’s staff.
17. Works closely with the business office and case management to ensure that observation hours are billed appropriately and any denied injection/infusion charges are rebilled timely.
18. Maintains confidentiality of patient identity and patient information.
19. Contributes to the efficient operations of the department.
20. Demonstrates commitment to professional accountability and growth to maintain and expand knowledge and skills.
21. Contributes to the achievement of the mission and philosophy of the Organization.
22. Contributes to the effective operations of the Organization by demonstrating dependability in job performance.
23. Demonstrates a commitment to incorporating the core concepts of patient family centered care into practice (dignity, respect, information sharing, and participation).
24. Demonstrates a commitment to the development and implementation of shared governance across the Organization.
25. Performs other related duties as assigned.

WORKING CONDITIONS, HAZARDS AND PHYSICAL EFFORT:

Works in a typical office setting. Moderate amount of time spent at the computer terminal. The tasks of this job do not involve exposure to blood, body fluids, or tissue. Must be able to move or position 25 lbs.

CONTACTS WITH OTHERS:

Interacts with Department Directors, Office Managers, Consultants, and Outside Auditors. Must be able to communicate effectively. Should be pleasant, conscientious, tactful and responsible.

EQUIPMENT USED/SPECIAL SKILLS REQUIRED:

Demonstrates proficiency in computer skills including word processing and spreadsheet utilization.