The Medical Compliance Specialist assist with ensuring that the clinical needs of individuals served are being met and maintained as per all state and federal regulations and in accordance with agency policy. This person will support new and existing Managers/Directors by completing regular audits of medical and other records to ensure compliance and assisting with the ne

The Utilization Review Specialist is responsible for the pre certification, concurrent, and discharge review process for clients at all levels of care, resulting in the approval of their admission and continued treatment. Job Duties and Responsibilities Consult with Admissions Department regarding specific LOC issues, insurance requests, and/or criteria questions. Complet

1. Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and to assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study. 1.1 Completes the initial review within 24 48 hours of admission.

Responsible for the tracking, coordination and communication of patient referrals in work queue. Collaborate with Practices to ensure complete and accurate patient registration, including demographics and current insurance. Assembles information concerning patient's clinical background in EPIC to help with referral. Contacts insurance companies to ensure verification of b

1. Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and to assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study. 1.1 Completes the initial review within 24 48 hours of admission.

As a valued member of the DRG Review Team, the DRG Integrity Specialist performs a secondary level review of medical records and code assignment using knowledge of Accuity technology and client systems with a physician in accordance with federal coding regulations and guidelines as well as client specific coding guidelines to ensure accurate DRG assignment. This function

1. Screens and refers incoming phone calls and directs patients and families to ensure that accurate and timely department communication is facilitated and that the Department is represented in a positive manner. 1.1 Provides all support and clerical assistance to patients, families, staff (both departmental and hospital), and community contacts with the greatest consider

1. Reviews medical record documentation and accurately selects the appropriate ICD 10 CM, CPT, modifiers, and ICD 10 PCS codes, when applicable, in accordance with official coding guidelines. This includes resolving CCI edits, as applicable. 2. Capable of coding a minimum of three (3) complex OP service lines, which would include Cardiology, Interventional Radiology, Obse

1. Follows department established Fax Review protocols. Extracts and summarizes pertinent clinical information to transmit to payors for reimbursement. 2. Proactively identifies potential concerns regarding clinical eligibility for admission and/or continued stay reviews and addresses with Care Coordination. 3. Coordinates reconsiderations and/or peer to peer reviews for

1. Coordinates activities with internal and external educational partners (Inpatient Coding Educator/Auditor, American Coding School, AHIMA Foundation Apprentice Program, Nosology, etc.) to identify cases for internal audits, American Coding School and for apprentice staff on an ongoing basis; and meet with staff to assess their knowledge of specific coding topics and ide

1. Screens and refers incoming phone calls and directs patients and families to ensure that accurate and timely department communication is facilitated and that the Department is represented in a positive manner. 1.1 Provides all support and clerical assistance to patients, families, staff (both departmental and hospital), and community contacts with the greatest consider

Review pre bill cases simultaneously with a physician during each work shift excluding breaks and meetings to analyze and validate diagnosis and procedure codes for inpatient services via coding compliance and clinical knowledge to support accurate DRG assignment Utilizes Accuity technology for tracking of coding errors, query opportunities and other data collection as ne

1. New Medical Staff Applications 1.1 Receives and reviews all new applications and communicates with applicant regarding outstanding required documentation within five (5) working days of receipt. 2. Medical Staff Re Appointments 2.1 Responsible for ensuring that re appointment applications are appropriately prepared and distributed to eligible Medical Staff six (6) mont

Assess the clinical indicators and suggestions of various query requests received from the MD Reviewer/ DRG Integrity Specialist Collaborate and communicate as necessary to clarify and avoid misinterpretation to ensure the query is optimally written and distributed to the correct client provider Creates queries in a compliant manner in accordance with AHIMA and ACDIS comp

1. Exhibits Ability To Prioritize Activities. 2. Assists Others In Obtaining And Sharing Pertinent Information. Notifies Appropriate Rn Or Department Of Stat Orders. Coordinates Desk Communication Activities During A Code Or Other Emergency Situation. 3. Knows Protocol Requirements And Sequences For Lab Tests, Radiology Procedures, And The O. R. Serves As A Resource To St