Conducts initial reviews of various medical record documentation to ensure the capture of all appropriate diagnoses/procedures related to reimbursement and compliance standards.

Abstracts outcome data as required by accrediting, regulatory, and voluntary agencies such as CMS, DOH, and NPA (National PACE Association).  Completes weekly checks to monitor for CMS and DOH guideline changes related to risk adjustment information.

Routinely reviews medical record information and coding to identify appropriateness based on CMS HCC categories.

Assures the accuracy, completeness, specificity and appropriateness of diagnosis information.

Verifies and ensures the accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered.

Identifies trends/problems in medical documentation and recommends solutions to the Health Information Director/designee.

Provides education and training regarding provider documentation via daily interaction with providers and other suitable training modalities to ensure capture of all applicable diagnoses/procedures related to reimbursement and compliance standards; writes monthly education newsletters.  Reports any trends and/or issues to the Health Information Director/designee.

Identifies medical services provided but not adequately documented in medical record.  Advises supervisor and clinicians of deficiencies to ensure accuracy, completeness and capture of maximum reimbursement.

Prepares provider profiles on a monthly basis, prepares utilization and various statistical reports and in collaboration with Health Information Director/designee assists in analyses as appropriate; acts as back up person for completion of risk adjustment reports.

Monitors compliance with procedures relevant to clinical data management; conducts monthly audits to monitor for the accuracy of clinical coding by PACE CNY providers and outside providers via hospital bills, etc. as part of the PACE CNY’s compliance program.  In conjunction with PACE CNY finance department, assist with claims analysis on incoming participant medical invoices; works closely with PACE CNY finance department to ensure compliance with CMS submittal guidelines for all outside medical encounters.

Keeps current with coding and reporting requirements and performs all necessary duties to maintain compliance.  As needed accurately completes diagnostic and procedural coding for PACE clinic providers based on clinical documentation.  Ensures timely processing and submission of encounter forms in order to comply with CMS & DOH timelines; also completes ancillary encounter diagnostic and procedural coding based on provider documentation as needed.

Reviews questionable or denied claims from PACE CNY contracted providers.  Completes medical chart review related to such claims and provides feedback to the Health Information Director/designee.

Keeps current on Correct Coding Initiative Edits and works with the PACE CNY finance department to ensure the adjudication system is updated appropriately.

Updates PACE CNY and McAuliffe encounter forms yearly and as necessary as new codes become available.

Acts as a resource for PACE CNY, the Loretto Geriatric Center Licensed Home Care Agency and various Loretto finance departments for reimbursement, compliance, and coding issues.

Completes audits related to reimbursement coding compliance, utilization management and QA related to record maintenance and Health Information releases on an ongoing basis.  Trends audit results and provides reports to the Health Information Director/designee.

Actively participates in staff meetings or other meetings as requested by supervisor.  Assists as requested in relevant committees, task forces and special projects to promote quality improvement initiatives.

Checks new enrollees’ initial visit provider diagnoses list versus diagnoses contained in old records to confirm the carry over of appropriate preexisting diagnoses.  Brings discrepancies to the provider’s attention.

Complete monthly statistical/demographic reports and distribute to appropriate personnel.

Conducts in-service programs relating to health information and/or reimbursement as required.

Provide assistance and back up help as requested to other areas of the Health Information Department.

Performs podiatry coding for McAuliffe ancillary department, meets with provider to review coding questions; providers ongoing education regarding coding changes/expectations/documentation requirements.

Demonstrates adherence to all compliance policies and procedures and the code of conduct.

Displays compliance oriented behavior in the workplace.  Is responsible for promoting and fostering compliance in the workplace.  Adheres to the mission and philosophy of the D & TC, PACE CNY and the Loretto Corporation.

Adheres to service excellence by developing and maintaining positive respectful relationships will all customers, internal and external, to include participants, families, team members, all staff throughout the organization and community partners; performs responsibilities according to the highest quality standards.

Performs other duties as assigned.

Employer’s Disclaimer:

■    All requirements are subject to possible modification to reasonably accommodate 

      individuals with disabilities.

■    Employees will be required to follow any other job-related instructions and to perform any

      other job-related duties requested by their supervisor.

■    This document does not create employment contract, implied or otherwise, other than an

      “at will” employment relationship.

■    This job description in no way states or implies that these are the only duties to be

      performed by the employee occupying this position.

Created:    10/12