Clinical Coding & Audit Specialist

Requisition: 2024-137732Clinical Coding & Audit SpecialistJob LocationsUS-KY-LOUISVILLEID2024-137732Line of BusinessBrightSpring Health ServicesPosition TypeFull-TimeOur CompanyBrightSpring Health ServicesOverviewThe Clinical Coding and Audit Specialist monitors, responds and performs the clinical coding and audit support required to ensure timely processing of all episodes of care. Reviews documentation for appeals processes across the Home Health enterprise for all payor types striving to improve clinical documentation and minimize lost revenue. Conducts analysis on timely submission of coding reviews and supports branches to prevent edit lock OASIS to be prior to the 30-day limit. Provide support and coordination with branches if re-coding records is required for sufficient billing practices to be met. This position will also support detailed level reporting and analytics, clinical appeals, root cause analysis, and address identified trends in reasons for denials related to coding and/or OASIS related documentation. Partners with Home Health operations and customers to drive improvement in the quality of services delivered to patients.ResponsibilitiesCode diagnosis accurately utilizing ICD-10 for purposes of reimbursement and compliance within coding regulations and guidelinesIdentify problems and follow up as needed with appropriate staff and/or department for correctionReview coding to ensure documentation is completed within Agency's admission timeframeEstablishes and promotes ongoing communications with Agency personnelCharged with responding, managing, and monitoring payer Additional Documentation Requests (ADR) and communications. Works with branch staff to gather required information and submits timely response to ADR requestsMonitors OASIS timing and collaborates with branch and billing staff to determine resolutionsAudits patient records for quality and compliance per applicable home health regulations for submission for pre-claim review process of Review Choice Demonstration and/or Targeted Probe and Educate recordsAudits patient records for quality and compliance per applicable home health/hospice requirements or for other projects per agency need including but not limited to improvement plans as part of targeted probe and educate surveys, performance improvement programs and patient safety surveysFormulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence-based medicine, local and national medical management standards, and protocolsPerforms ad hoc audits and reporting per requestAnalyzes information gathered by audits and reports and makes recommendations for changes to or development of policy/process and educationTracks audit result reporting results and shares with all interested stakeholders (e.g., compliance, legal, clinical support, and local operations & clinical staff)Acts as a resource and has expert knowledge of Medicare, Medicaid, ICD-10 Coding and OASIS and other applicable regulatory requirementsProvides consultation and education for clinical staff as needed to ensure accurate, timely, compliant documentation that drives accurate billing QualificationsClinical review positions will require a RN degree in nursing from an accredited or approved schoolTwo years of experience in health care utilization review or home health careClinical review will require a current license/registration by state of hire as a nurseSuccessfully completed HCS-D coding certification, required and to be maintainedSuccessful achieve of OASIS certification, required to be maintainedExpert written and verbal communication skillsStrong presentation skills to various audiencesStrong interpersonal skillsA thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirementsExtensive knowledge of Home Health or Hospice operations, compliance requirementsExtensive experience in working with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC responsesAbility to prioritize tasks and manage multiple projectsStrong analytical and problem-solving skills with attention to detailAbility to utilize a personal computer and other office equipmentProficient use of Electronic Medical Record softwareProficient use of Microsoft Office Suite-Excel, Word, and PowerPointSolid ability to learn new technologies and possess the technical aptitude required to understand flow for data through systems as well as system interactionAbout our Line of BusinessBrightSpring Health Services is a leading provider of complementary home and community-based pharmacy and health services for complex populations in need of chronic and/or specialized care. Through the company's pharmacy and provider services to seniors and specialty (including behavioral) populations, we provide comprehensive care and clinical services in 50 states to over 360,000 customers, clients and patients daily. The company's services foster greater patient and family satisfaction, improve outcomes and reduce health care system costs, and are supported by industry-leading quality outcomes. For more information, visitwww.brightspringhealth.com. Follow us onFacebook,TwitterandLinkedIn.Res-Care, Inc., dba BrightSpring Health Services (“ResCare”), is an Equal Opportunity Employer. ResCare does not discriminate against any person on the basis of gender, r ace, color, national origin, r eligion, disability, age, veteran status, gender identity or s exual orientation in admission, treatment, or participation in its programs, services and activities, or in employment, or on the basis of gender in its health programs and activities.