Location: New York,NY, USA
About NYC Health + Hospitals:
Empower Every New Yorker — Without Exception — to Live the Healthiest Life Possible
NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Job Description:
SUMMARY OF ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Performs retrospective current and/or longitudinal reviews for completeness. In addition, substantiate all ICD-CM and Procedural Coding System (PCS) diagnostic and therapeutic procedures are reported affecting utilization and statistics.
2. Performs secondary level reviews to validate the completeness, accuracy, and specificity of code assignments for inpatient records in accordance with established coding guidelines and enterprise policies and procedures for appropriate DRG assignment. Ensures that all documented diagnoses and procedures are properly coded.
3. Validates the completeness, accuracy, and specificity of code assignments for emergency, outpatient and ambulatory surgery records in accordance with established coding guidelines to support HCC capture and CRGs.
4. Participates in data quality reviews on inpatient records to validate the ICD-10 codes, MS-DRG, and APR-DRG, identify missed secondary diagnoses and procedures, PSIs, HACs and ensures compliance with all DRG mandates and reporting requirements. Analyze reports and identifies trends and statistical significance in quality metrics that will assist with focused as well as organizational process improvement.
5. Participates in the denials and appeals process by reviewing cases denied and making the determination whether or not a case is appealable by using pre-established criteria, based facility policies and procedures. Ensures denials are responded to in a timely manner. Provides feedback to facility coders, validators and physician advisors on opportunities in collaboration with CDI.
6. Generates physician queries based on documentation and clinical indicators for suspected conditions that impact quality and/or reporting, so the physician may consider a definitive diagnoses and/or document clarification of specificity as requested into the health record. Provides feedback to facility staff on missed opportunities for documentation improvement. Ensures adherence to established policy and procedures.
7. Engages in the evaluation of administrative systems employed in maintenance and utilization of health information records. Performs data quality assurance reviews for system functions and usage.
8. Analyzes usage reports to identify trends in documentation inconsistencies, inadequacies and other issues to determine root cause, including but not limited to focused reviews i.e. Patient Safety Indicators (PSI) and Hospital Acquired Conditions (HAC) and identify process improvement opportunities in collaboration with the Quality professionals.
9. Performs post-billing quality reviews and analysis of coding edits to identify resolution, automation, education or re-training to facilitate the processing of clean claims for billing.
10. Participates in the denial review process to establish evidence of clinical or documentation to support the current billing which may include writing an appeal letter with said evidence to retain proper reimbursement. Ensures all denials are responded to in a timely manner for tracking and provides feedback to appropriate staff, as needed.
11. Educate and mentors facility coding and validation staff. Provides orientation and boot camp training which includes new topics in coding (inpatient and outpatient), chart review, reimbursement and regulatory changes. Provides readiness assessments of new coding staff.
12. Assists in the development, implementation and management of performance standards and strategic planning through preparation and/or presentation of financial statistics for Enterprise-level reporting for physician advisors, clinical leadership and key stake holders.
13. Responsible for maintaining knowledge of regulations and updates in the reporting of ICD codes, disease pathophysiology and documentation requirements. Provides updates to staff, as necessary.
14. Participates in the development and/or facilitating of training programs that provide systemwide education on documentation requirements in various healthcare settings, reimbursement and regulatory changes. Participates in facility new associate orientation, instructs and mentors appropriate staff, as needed.
15. Acts as a subject matter expert resource and liaison with internal and external professional groups. Acts as a departmental representative on various committees or work groups. Assists in interdisciplinary efforts to review existing documentation and coding policies and procedures and makes necessary recommendations for improvement.
16. May participate in performance measures and research activities.
17. Performs related duties, as assigned.
Minimum Qualifications:
1.Three (3) years of clinical experience as a Registered Professional Nurse (RN) and an additional two (2) years of Clinical Documentation experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or
2. One (1) year of clinical experience as a Nurse Practitioner (NP) or Physician Assistant (PA) and an additional two (2) years of Clinical Documentation experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or
3. Medical School Graduate; and two (2) years of medical record review, utilization review or case management experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or
4. Valid Registered Health Information Administrator (RHIA) credential from the American Health Information Management Association (AHIMA) or a Registered Health Information Technician (RHIT) credential from AHIMA; and three (3) years of satisfactory experience in Diagnosis-Related Group (DRG) validation and coding; or
5. High school diploma or its educational equivalent; and valid coding certificate from a nationally accredited association (i.e., Certified Coding Specialist (CCS) from AHIMA or Certified Professional Coder (CPC)); and six (6) years of satisfactory experience in coding, abstracting medical records and DRG validation in a healthcare environment.
Department Preferences
NYC Health and Hospitals offers a competitive benefits package that includes: