System Professional Coding Quality and Review Manager

Job Title: Manager

Location: System Business Office

Department Name: HIM – Professional

Req #: 0000207263

Status: Salaried

Shift: Day

Pay Range: $100,619.00 – $142,124.00 per year

Pay Transparency:

The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate’s educational background, skills and professional experience.

Job Summary:

The System Professional Coding Quality and Review Manager is responsible for reviewing physician medical records (professional billing) in the outpatient and inpatient settings to ensure complete and accurate code assignment and compliance with appropriate coding guidelines and state and federal regulations. This position will manage the coding auditing staff and distribute work equitably, review audit results for accuracy and provide education to staff as needed.

The selected candidate for System Professional Coding Quality and Review Manager must be prepared to engage in cross-functional duties for the System Professional Provider Review and Education Manager, as aligned with organizational priorities and leadership guidance. These may include supporting provider education efforts, participating in the creation and delivery of training sessions, conducting medical record audits, supporting coding operations and contributing to administrative functions as needed. Managers must also be prepared to support each other in cross-functional oversight of coding staff as needed and directed.

Qualifications:

Required:

• CPMA and either CPC or COC required with at least 8-10 years of professional coding audit experience.
• Associate degree or equivalent experience required.
• Minimum three to five years of experience in a managerial position.
• Minimum three to five years of experience working coding denial/edits, including LCD, NCD and medical necessity.
• Must have a broad-based and thorough understanding of ICD-10 CM diagnosis coding and CPT/HCPCS systems.
• Extensive working knowledge of NCD/LCDs, AHA Coding Clinics for ICD-10-CM/PCS and HCPCS, CPT Assistant and other regulatory guidance with demonstrated ability to research.
• Requires a solid understanding of third-party hospital payer requirements, guidelines, government regulations and coding compliance.
• Strong knowledge of Revenue Integrity and/or medical necessity requirements
• Must be proactive and work independently to prioritize multiple tasks and changes in work assignment to meet established deadlines.
• Must be able to work in a fast-paced healthcare environment, work well under pressure and have the ability to adapt to a constantly changing environment.

Scheduling Requirements:

• Full-Time, Salaried position- 37.5 hours a week
• Travel to Oceanport, NJ as needed. Some travel may be required for on-site education or audits across RWJBH medical centers.

Essential Functions:

• Performs physician coding reviews and provides detailed written and verbal feedback to management and providers as directed. Ensures accuracy and integrity of ICD-10-CM and CPT procedure coding for professional fee accounts for the purpose of maintaining compliance with Federal and State Coding Regulations.
• Prepares annual Physician Review Work Plan based on yearly billing reports for employed providers applied to CMS Evaluation and Management (E/M) benchmarks (“Heat Map”) in collaboration with Manager.
• Conducts Joint Venture (IPA) coding reviews as requested.
• Performs coding audits based on referrals from physician management, outside payers, and review organizations.
• Works collaboratively with Physician Reviewers in distribution of provider review assignments throughout the Work Plan phases. Ensures equitable distribution of additional provider reviews as requested with Management oversight.
• Provides secondary provider audit review as necessary.
• Conducts employed provider coding audits according to the current year Work Plan, in accordance with new provider on-boarding (pre- and post-acquisition), and as per Corporate Compliance requests.
• Performs risk assessment analyses to identify potential aberrant processes and recommends reviews of providers as needed.
• Monitors OIG Work Plan and CMS Guidelines and maintains related shared organizational repository.
• Reviews ICD-10-CM, HCPCS and CPT coding performed by employed providers and/or affiliate staff for accuracy and completeness.
• Maintains a deep knowledge of Evaluation and Management (E/M), split/shared and incident to guidelines to provide thorough coding audits and accurate information.
• Works collaboratively with providers and affiliate staff to promote and ensure correct and compliant coding and billing practices.
• Works collaboratively with System Professional Provider Education and Coding Manager to distribute follow up review education needs. Provides audit results, coding references, and other materials associated with completed reviews of employed providers, including research, and associated research documentation.
• Prepares and maintains detailed reports of review activities and tracks audits in a master spreadsheet. Produces other reports as requested by management.
• Effectively communicates coding recommendations and reasoning to medical staff members and others.
• Performs regulatory coding research for Compliance Department and/or employed providers and affiliate staff.
• Performs physician RAC coding reviews and prepares appeals when warranted.
• Assists internal and external Compliance counsel in external agency investigations as required.
• Corresponds with AMA and related organizations with coding questions as necessary.
• May be required to assist in the formation of Corrective Action Plans for the employed physicians and affiliate staff.
• Performs other duties as assigned.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Benefits and Perks:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees’ physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey-whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer