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  • Orange, CA

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Clinical Documentation Specialist (RN) - Claims

CalOptima • Orange, CA

Posted 1 month ago

Job Snapshot

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Job Description

The Clinical Documentation Specialist (RN) provides clinical code expertise regarding claims editing, reimbursement rules, clinical coding, clinical rationale and decision making of hospital and professional claims. This position will be responsible for overseeing the vendor’s submission(s) to ensure coding and claims guidelines are followed according to the regulatory standards.  The incumbent will perform analysis on all data to assure the logic set forth by the vendor(s) meet applicable standards.  The incumbent serves as a liaison with CalOptima’s claims vendors regarding data anomalies, claims editing, claims guidelines, feedback and identification of claims that require further review, investigation and supporting documentation.   


Position Responsibilities:

  • Conducts coding audits of submitted claims, which includes but not limited to review of professional, in-patient and out-patient claims data and/or medical records to determine appropriateness of procedures and diagnosis codes billed.
  • Responsible for creating a standardized audit tool for review of hospital, outpatient and professional claims to ensure consistency and appropriateness of audit reviews.
  • Develops audit reports of audit findings at both the detail and summary level with month to date and year to date metrics, and recommendations for program improvements.
  • Gathers and analyzes information and summarizes findings and metrics pertinent to documentation of chart review investigations; shares information with impacted departments.
  • Assesses medical records as applicable to ensure they substantiate services billed; shares anomalies identified with code review team and recommends areas for follow-up.
  • Reviews claims billed for the appropriate CPT, ICD-10, HCPCS codes and modifiers as applicable.
  • Ensures issues related to compliance reimbursement bundling/unbundling plus fragmentation of coding information are monitored.
  • Reviews high dollar professional and facility claims to validate charges paid to ensure documentation supports level of care billed.
  • Analyzes health claim history reports to identify coding as well as billing patterns and determines the appropriateness of the ICD-10-CM/PCS, CPT, HCPCS or revenue codes billed.
  • Maintains current knowledge of official healthcare regulations including reimbursement and documentation requirements professional claims billing, and industry standards include CPT, AMA, National Correct Coding edits for both Medicare and Medi-Cal, Centers for Medicare and Medicaid Benefits Manual, Medi-Cal provider manual, as well as other information published by various medical specialty societies concerning coding and reimbursement.
  • Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and adheres to official guidelines.
  • Assists management in medical claims processing studies to define claims editing trends.
  • Documents root-cause as well as recommends system and operational changes in methods, procedures and policies to improve quality and consistency with industry standard coding guidelines.
  • Other duties and projects as assigned.

Job Requirements

  • Gather and analyze claims and medical record information pertinent to documentation findings and outcomes.
  • Requires strong written, verbal, communication skills.
  • Work independently and in a collaborative setting.
  • Analyze data and apply clinical skills.
  • Work with minimal supervision.
  • Provide expertise regarding triage of claims to determine ones handle in house and those that require vendor review.
  • Identify patterns, trends, variances and opportunities to improve documentation review processes.
  • Demonstrate adaptability and flexibility in the face of changing demands. Contribute ideas to help improve processes and abstracting data.

Experience & Education:

  • BSN or bachelor’s degree in a healthcare-related field preferred.
  • Current active, unrestricted license as an RN in California.
  • 3+ years minimum experience as a registered nurse. 2 years (recent) focused on in-patient coding, healthcare and coding regulations including code structure, clinical documentation, DRG experience, criteria-based chart reviews (ex. Utilization Management or Case Management).
  • Utilization review experience is preferred.
  • Current certification as CCDS, CDIP, CCS, CPC, CCI or RHIT is required or 3 years of equivalent experience in utilizing CPT, HCPCS, revenue codes, ICD-10 CM and PCS coding guidelines.

Knowledge of:

  • Must have knowledge of claims processes.
  • Requires Medicare and Medi-Cal coding guidelines and billing protocol.
  • Requires knowledge of hospital care delivery systems, levels of care, hospital coding practices and billing systems.
  • Clinical anatomy and physiology, patho-physiology, pharmacology, and medical terminology.
  • CMS coding guidelines, principles and conventions.
  • AHA coding clinics guidelines to accurately determine the principle and secondary diagnoses and procedures that impact both MS and APR DRG assignments.  
  • Microsoft Word, Excel, and PowerPoint.

Grade:  O



Job ID: 18033-022019
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