Level 1 Outpatient Claims Nurse Coder Analyst

Department: Consumer Division
Direct Report: Missy Conley, Director Consumer Division
Sec. Report(s): Jeanne Woodward, Vice President Consumer Division
Location: Roanoke, VA.

POSITION SUMMARY

The Level 2 Outpatient and Professional Claims Analyst is responsible for performing outpatient and professional compliance bill reviews and research as necessary to determine the accuracy of charges billed by facilities and professional providers. Compliance review includes but is not limited to the UB-04, detailed itemized statement, CMS-1500, coding guidelines, medical records, plan benefits, explanation of benefits, and additional documentation related to claim/s. Level 2 Outpatient Claims Analyst will consult with Senior Claims Analyst with questions and/or issues related to claim reviews. Level 2 Out-patient Claims Analyst will obtain approval from Claims Analyst Manager prior to pending any claim. The Level 2 Claims Analyst assists the Claims Analyst Manager on special client projects and/or development of edits in the Consumer Software Program.  The Level 2 Outpatient and Professional Claims Analyst will assist in training of new Level 1 employees.

DUTIES AND RESPONSIBILITIES

Specific Duties Include:

  • Compliance Review of UB-04
    • Perform hospital coding analysis i.e. MUE’s, HCPCS/CPT and ICD-10-CM Codes
    • Review system’s initial scrub results (including CIA and HAC checks)
    • Delete false errors
    • Add additional errors identified from manual review
    • Pend claim when appropriate
    • Make notes in system related to review
    • Other UB-04 issues as needed
  • Compliance Review of CMS-1500
    • Perform professional coding analysis i.e. MUE’s, HCPCS/CPT and ICD-10-CM Codes
    • Review system’s initial scrub results (including CIA, etc.)
    • Delete false errors
    • Add additional errors identified from manual review
    • Research billing and coding issues as needed.
    • Pend claim when appropriate
    • Make notes in system related to review
    • Other CMS-1500 issues as needed
    • Compare CMS-1500 to UB-04 for any coding discrepancies and inconsistencies
  • Compliance Review and/or Detailed Itemized Statement
    • Review system’s initial scrub results
    • Delete false errors
    • Review CPT codes for unbundling, MUEs, multiple procedures, etc.
    • Review for in-patient codes on out-patient bills
    • Add additional errors identified from manual review
    • Pend claim when appropriate
    • Make notes in system related to review
    • Other itemized statement issues as needed
  • Medical Record Review (If Applicable)
    • Compare medical record documentation to UB-04, CMS-1500, and itemized statement
    • Document errors identified
    • Make notes in system related to review
    • Pend claim when appropriate
    • Other medical record issues as needed
  • Pricing Analysis (If Applicable)
    • Obtain hospital CMS certification number
    • Run Out-patient pricer
    • For Professional claims, compare Medicare’s area fee schedule vs charge
  • Complete Pending Form Request 
    • Complete Pending Form when necessary
    • Obtain approval from Claims Analyst Manager
    • Make notes in system related to Pending Form
  • Submit Completed Review
    • Send completed review to Claims Closing Specialist
  • Assist Director of Hospital Accounts and Claims Analyst Manager
    • Assist Compliance and Resolution with appeals when required
    • Research skills to include medical policies, CMS Manual, CMS’ NCD, CMS’ LCD, OIG, top fraud and abuse billing issues, and more.
    • Other special client projects as needed

 MINIMUM STANDARD REQUIREMENTS, SKILLS, AND ABILITIES

  • Certified Professional Coder with focus on surgical coding. At least two years of in-depth coding experience
  • Prefer outpatient hospital coding experience
  • RN or LPN in facility setting preferred but not required
  • Two years of experience working in excel and access programs
  • Proficient data entry skills with accuracy
  • Great attention to details and accuracy
  • Ability to follow procedures

INTENT AND FUNCTION OF JOB DESCRIPTIONS

Job descriptions assist organizations in ensuring that the hiring process is fairly administered and that qualified employees are selected. They are also essential to an effective appraisal system and related promotion, transfer, layoff, and termination decisions. Well-constructed job descriptions are an integral part of any effective compensation system.

All descriptions have been reviewed to ensure that only essential functions and basic duties have been included. Peripheral tasks, only incidentally related to each position, have been excluded. Requirements, skills, and abilities included have been determined to be the minimal standards required to successfully perform the positions. In no instance, however, should the duties, responsibilities, and requirements delineated be interpreted as all-inclusive. Management reserves the right to modify, add or remove essential functions as business needs warrant. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

In accordance with the Americans with Disabilities Act, it is possible that requirements may be modified to reasonably accommodate disabled individuals. However, no accommodations will be made which may pose serious health or safety risks to the employee or others or which impose undue hardships on the organization.