PRMO: , established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke PrimaryCare. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke's reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.
General Description of the Job Class
Coordinate/review the work of vendor outsourcing partners and assist with the training and continuing education programs. Code medical records utilizing ICD-10CM, CPT-4 and HCPCS Level II coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement professional charges. Abstract information from medical records following established methods and procedures.
Duties and Responsibilities of this Level
Ensure quality and quantity of work performed through regular audits and QC for vendor services specifically in coding denials and coding appeals
Monitor and track outsourcing vendor performance as it pertains to QC, Productivity, Timely Filing and High Dollar accounts
Review and research the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-9-CM/ICD-10 CM and/or CPT, HCPCS coding conventions and payer specific coding guidelines.
Develop and assist training, presentations and educational tools for any relevant topic as it relates to continuing education programs on areas of specialization, coding, operational workflow and quality control.
Collaborates with other departments and partners (e.g. Revenue Integrity, QA Team, Compliance Specialist, Internal Controls, Billing and Collections and Revenue Managers) to ensure coding feedback to outsourcing vendors and team are provided.
Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
Consult with and provide feedback to physicians or department on coding practices and conventions in order to provide detailed coding information. Communicate with clinical, ancillary staff and revenue managers for needed documentation to ensure accurate coding.
Develop and maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-9-CM/ICD-10 CM and CPT-4 coding guidelines to inpatient/outpatient diagnoses and procedures.
Develop and maintain thorough understanding of medical record practices, standards, regulations, Health Care/Finance Administration (HCFA 1500) and Uniform Billing (UB-04), CMS, Outpatient Prospective Payment System (OPPS), other payer policies and any health care relevant changes.
Develop and maintain a thorough understanding of payer specific guidelines as it pertains to edit review, denial management, claim returns and rejections.
Ensure active participation in any team event and departmental activities in the PRMO and DUHS
Ensure compliance to PRMO and DUHS policies and code of conduct
Assist with special projects as required
Medical Records Coder II - Vendor Support - Coding Appeals & Denials
This position is a progressive coder/auditor role that is accountable for key strategic vendor education that provides the opportunity for development in ensuring coding accuracy for the vendor services. The ideal candidate has experience and knowledge in coding/billing, denials, payer guidelines as well as well-developed analytical skills in this area. The position is a forward facing role that will have regular access / communication to our coding vendor partners. Coding certification is required and additional certification for auditing is preferred.
Quality Control - (40%)
Review of vendor work to identify erroneous coding patterns and errors
Providing feedback and education to vendor services to address issue found in Phase 1 audit and appeals
Monitoring and tracking of QC result
Provide coding process analysis and support for the department as an expert for Outsourcing partner QC team and supervisors
Vendor Education (30%)
Plan activities aimed at improving the Coding Vendor's quality performance in operations
Design and implement strategies for enhancing vendor's work quality and increasing productivity.
Evaluate effectiveness of improvement strategy through sustained tracking and monitoring of vendor's related WQ.
Reporting of vendor specific trends and issues to upper management
Performing actual coding function including but not limited to charge review edits, coding denials, rejections and coding validations
Cross coverage to other coding QC processes and workflow
Performing necessary research and investigation to resolve coding related issues and enhancement of the business process associated with job functions and responsibilities
Maintaining coding skill by continuing education and keeping abreast to regulatory healthcare related changes and payers rule update
Required Qualifications at this Level
High school graduate, Bachelor is preferred
Minimum of 3 years work experience of Coding and/or Auditing experience
Degrees, Licensure, and/or Certification:
CPC, CPC-P, CCS, CCS-P, CPMA
Knowledge, Skills, and Abilities:
Effective written and verbal communication skills
Ability to communicate with customers/staff with diverse educational backgrounds
Ability to provide feedback and education in a group setting or over WebEx
Analysis of data and processes for opportunities for improvement
Attention to detail and accuracy
Distinguishing Characteristics of this Level
Be able to teach coding effectively to a diverse environment
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas--an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.