Coding Data Quality Analyst
The Coding Data Quality Analyst (CDQA) plays a crucial role in ensuring the accuracy and completeness of encoded data used for hospital reimbursement, clinical quality and administrative reporting for Munson Healthcare system hospitals.
The CDQA is a medical coding professional who works to prevent reimbursement denials by participating in the responses to third party payers regarding overpayment disputes related to clinical documentation, code assignment, medical necessity, and modifier issues. This role is key to protecting reimbursement and minimizing organizational write offs.
The CDQA works to ensure payment integrity by conducting comprehensive reviews of medical record documentation and subsequent coding for accuracy and completeness. This position assists the Data Quality Coordinator in conducting coding audits, maintaining related statistics, identifying trends and making recommendations for improvements. The CDQA effectively uses abstracting databases, internal and external audit results, various federal or State quality reports, and revenue cycle edit/denial information.
A perpetual student of ever-changing healthcare coding rules and clinical documentation improvement practices, the CDQA stays abreast of dynamic changes to proactively prevent errors and financial penalties from occurring and assists the Data Quality Coordinator with developing recommendations and education proposals related to the changes.
As a member of the Department's Leadership team, this position requires effective interaction with both Coding and CDI staff and different levels of management. The CDQA works closely with the Coding/CDI Physician Advisor, Regional Coding Manager, Coding/CDI Educator, individual medical staff members, Coder/Abstractors, CDI Specialists, Business Office staff, and Clinical Department management in resolving questions relative to coding, documentation and denials.
This position requires independent decision making on a routine basis. There is significant latitude to investigate technical problems and to take independent action based on the findings.
This position requires an Associate's Degree in Health Information Technology, or a Bachelor's Degree in Health Information Management.
Current certification as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is required.
Requires a minimum of three years coding experience in a hospital setting.
Management or other leadership experience is preferred.
Previous experience in educating, evaluating and communicating the results of Coders' quality is preferred.
Demonstrated ability in working and problem solving with hospital medical staff, clinical and financial department staff is required.
Demonstrated ability to effectively handle sensitive and high-stress situations, establish priorities and meet tight deadlines is required.
In-depth knowledge of prospective payment regulations, DRG and APC grouping, National and Local Coverage Determinations, and ICD-10-CM and CPT classification systems is required.
Experience with Microsoft Office spreadsheet and database software is required.
Must possess strong analytical and interpretive skills, with a propensity for thoroughness and detail.
Demonstrated ability to analyze data, problem solve and implement solutions is required.
A working knowledge of The Joint Commission standards and State of Michigan regulations related to medical record documentation is required.
Excellent verbal and written communication and organizational skills required.
Previous experience with 3M HIS and Cerner PowerChart applications is desirable.
The Coding Data Quality Analyst reports to the Regional CDI Manager and works under the general guidance of the Regional Data Quality Coordinator, assisting with many routine and special functions.
Supports the Mission, Vision and Values of Munson Healthcare. Embraces and supports the Performance Improvement philosophy of Munson Healthcare. Promotes personal and patient safety. Uses effective customer service/interpersonal skills at all times. Researches payor denials and initiates or assists in appeal writing process. Based on findings of reviews, identifies opportunities for improvement educational programs and submits a report of the findings and recommendations. Communicates any ICD-10 and CPT coding, DRG and/or APC updates published in third-party payor newsletters, bulletins and provider manuals, AAPC or AHIMA updates to the Leadership team for distribution and education of Coding and CDI staff. Participates in various process improvement teams such as the CDI Query Development team. Reviews CMS Federal Register proposed and final rules and the current OIG Work Plans for compliance, then provides staff with updates concerning changes to the plans. Provides relief coverage of Coding and Data Quality positions when requested. Assists with the detailed writing and timely submission of appeal letters to external auditors/payors based on review of medical records and in accordance with payor guidelines as well as MHC policies and procedures. Identifies denial patterns and escalates to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution. Reviews payor communications, identifying risk for reimbursement loss related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate Assists with complex, specialized coding and follow-up workflows including but not limited to researching the coding and CDI impact of new procedures and charges, working in collaboration with clinical department managers. Assesses current compliance activities, identifying areas of high risk, and evaluating risk factors in coding and documentation practices. In partnership with appropriate personnel, develops and implements standardized, organization-wide coding guidelines and documentation requirements. Performs routine coding and CDI staff quality audits, summarizes findings, reports to management, and assists in development of presentations to educate staff and clinicians. Provides input into performance evaluations of coding staff as it relates to the quality of their work. Analyzes, summarizes and educates staff on new or revised regulatory changes related to coding, hospital-acquired conditions and Patient Safety Indicators (PSIs). Orient and train new employees and students as it relates to Data Quality activities. Assist in the preparation of monthly team meetings. Provides input on new staff hiring decisions. Performs other duties and responsibilities as assigned.