Coding Compliance Specialist researches and develops the pre-certification insurance policy standards and criteria used by case management and utilization reviewers that will ensure that requested medical services are appropriate and medically necessary. Collaborates with medical professionals to resolve questions about policy development and standards. Being a Coding Compliance Specialist assigns correct ICD, CPT, or other coding assignments for medical procedures that support policy standards in claims systems. Provides expertise and solutions to users regarding the appropriate coding for claims. Additionally, Coding Compliance Specialist has broad knowledge of medical coding systems. May require an associate degree in healthcare administration, a related field, or equivalent. Requires AAPC Certified Professional Coder (CPC). May alternatively require Certified Coding Specialist (CCS) certification. Typically reports to a manager. The Coding Compliance Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Coding Compliance Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
Education: Graduate of Health Information Management or similar coding course. Associate degree or higher preferred. Certified by American Health Information Management Association as CCS, or CCSP, RHIT, RHIA .
Training and Experience: Credentialed as a Certified Coding Specialist by American Health Information Management Association. Minimum of 1 year experience coding health records; must be capable of following verbal or written instructions and should practice diplomacy in dealing with the Medical Staff. Will participate in ongoing education through workshops, in-service programs, and updates from CMS and other payors.
Job Knowledge: Must be familiar with medical terminology, able to follow coding guidelines with ability to identify proper diagnostic and procedural phases utilized by healthcare provider. Should have knowledge of anatomy and physiology of human body in order to obtain proper ICD and CPT codes. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association. Must be able to communicate verbally and in written format with the Medical Staff, review organizations, administration and others as required.
DESCRIPTION:
Should have the ability to work under pressure and meet productivity standards consistently. Associate needs considerable initiative and judgment involved in collecting and analyzing medical record data. Works under the supervision of the Director of Medical Record Department performing duties in an area where procedures are standardized, but where frequent independent decisions are required. Help maintain a quality improvement system to assure effective utilization of hospital facilities and services. Assist in the promotion and maintenance of high quality care through review of clinical practices within the hospital based on pre-established criteria. This will promote proper utilization of hospital resources to provide efficient cost effective, high quality patient care.