Job Information
UPMC Sr. Manager, Clinical and Coding Review - Quality Assurance and Operational Integrity in Pittsburgh, Pennsylvania
UPMC Health Plan is looking for a Senior Manager, Clinical and Coding Review to join the Quality Assurance team!
Directs and coordinates activities of workers engaged in audit activities related to diagnosis, CPT/HCPC and HCC. Creates and implements review processes to address identified new risks. Responsible for the creation and maintenance of audit tools, business flows, policies and procedures and other auditing functions. Participates as a member of the management team in formulating, establishing, and maintaining department budgets, policies and procedures, quality assurance measurements, and a high caliber team oriented working environment. Creates goals and objectives to address the organization?s mission, values and standards of conduct. Monitors that standards of quality and production of work are met or exceed service requirements. Specifically, is responsible for quality review/monitoring of Health Plan Coding Specialist Staff/or external coding personnel. Performs auditing functions including monitoring, coding of diagnosis, reviewing medical record documentation and discharge summaries to determine if appropriate code was assigned to ensure Health Plan compliance with coding standards. Provides clinical and coding related guidance and analysis to internal QA, F&A, Complaints & Grievances staff as needed.This position functions in a senior management role, with primary responsibility for overall operation of the Quality Assurance & Operational Integrity Coding review team. Works with internal and external customers, senior management, UPMCHS and UPMCHP department representatives, and vendors as necessary.
Responsibilities:
Directs and coordinates activities of auditors engaged in audits of HCC and other coding activities, including: Review the coding of diagnoses and verifying the proper ICD-9-CM codes were assigned by the HCC Coding Specialist. Ensure that all codes are documented for the assignment of a valid and accurate Hierarchical Condition Category (HCC). Monitor the assignment of the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology and pathology. Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure. Determine diagnoses that were treated, monitored and evaluated and procedures done during the episode of care to validate that the appropriate codes were assigned by the HCC Coding Specialist.
Oversee monthly quality reviews of implemented policies
Ensures that all turnaround times and quality measurements are met.
Communicates/coordinates activities with staff and customers to ensure delivery and completion of assignments, projects, and other performance commitments.
Coordinates ICD 10 implementation and follow through for QA/F&A department.
Recruits and manages staff that performs audit activities.
Assist with the National Risk Adjustment reviews and audits
Analyzes, evaluates, and presents information concerning factors, such as business scenarios, production capabilities, and design and development of department workflows.
Identify high risk HCC diagnosis codes, oversee review processes and distribution of findings to customers
Manages coding audit staff, including the completion of staff performance evaluations.
Ensures ongoing assessment of team needs related to staffing, audit tools and training.
Identifies critical business objectives, develops and operationalizes business plans to support critical objectives.
Working with PACE vendor on quarterly HCC reviews, update review processes, audits, summaries and meeting as need with external reviewer.
Serves as an instructor and discussion leader.
Creates inventory audit maintenance and reduction plans.
(Continued) Directs and coordinates activities of auditors engaged in audits of HCC and other coding activities, including: Completion of special projects including claims and/or coding related audit support. Communicate effectively with Risk Adjustment Staff, nurse reviewers and physicians and ancillary departments as necessary to address issues and concerns. Utilize standard coding guidelines and principles and coding clinics to verify that the appropriate ICD-9-CM and CPT codes were assigned including modifiers for correct DRG/APC assignment and accurate reimbursement. Clinical guidance and support to Fraud and Abuse department. Clinical review for high dollar claims and other clinical guidance as needed for Quality Audit department.
Oversee and interact with external vendor conducting automated and complex reviews. Mediating internal/external inquiries of vendor completed reviews, oversee the financial recovery processes and implementation of new processes
Prepares and maintains auditing statistics and findings for reporting to Operations and clinical departments, Senior Management and vendors.
Together with the Director, participates in the development of the Quality Auditing Department Budget.
Provides clinical and coding guidance to Fraud and Abuse department.
Perform higher level coding and clinical audits, identifying associated risk, requesting and reviewing medical records summarize audit findings and distribution of audit findings.
Continuously evaluates and documents customer needs, performs analysis of client business issues/concerns, participates in identifying solutions, and ensures that the appropriate resolution occurs.
Maintains a positive work environment for staff members, to support the experience, skill, knowledge and capabilities of employees.
Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) related to medical record documentation or a certified coding program such as American Academy of Professional Coders (AAPC) required.
7 years of progressive/leadership experience in clinical auditing/coding/or related within a health care or health insurance setting required. 2 years of directly related experience in a supervisor or Manger capacity strongly required
Experience and knowledge of reimbursement and clinical/procedural coding, claims processing, multiple lines of business, auditing and benefit plans and design.
Extensive knowledge of ICD-9/ICD 10 and CPT classifications and coding of diagnoses and procedures is required.
In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.
The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential.
Excellent written and verbal communication skills are essential.
Proficiency in computer skills required for coding.
Detail oriented individual with excellent organizational skills
High degree of oral and written communication skills.
Strong leadership skills and abilities, and strong independent decision-making skills.
Expert process and project management, negotiation, and analytical skills.
Excellent organizational, interpersonal and conflict management skills.
Proficiency in Microsoft office software applications.
Licensure, Certifications, and Clearances:
Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran