Clinical Reimbursement Manager- MSH- Medical Records Dept- FT Days

Job Description

Strength Through Diversity

Ground breaking science.  Advancing medicine.  Healing made personal. 


Dept Name-     Medical Records             REQ # 2471182


Job Title: Clinical Reimbursement Manager  


Roles & Responsibilities:

The Clinical Reimbursement Manager is responsible for performing quality reviews on medical records to validate the ICD-9-CM codes, DRG appropriateness, missed secondary diagnoses and procedures, and ensure compliance and accuracy of the MS-DRG and APR DRG. The Clinical Reimbursement Manager will continuously evaluate the quality of clinical documentation and monitor the appropriateness of physician queries with the overall goal of improving physician documentation through physician education and feedback and achieve accurate coding to support the optimal allowable reimbursement. The Clinical Reimbursement Manager works closely with the Coding Compliance Coordinator and Coding Compliance Manager to provide coding staff with feedback to assure coding uniformity, consistency and accuracy with ICD-9-CM and CPT-4 guidelines, UHDDS, sequencing guidelines, Federal and State regulations and the American Hospital Association coding guidelines and its publication Coding Clinic and AMA's publication CPT Assistant. The Clinical Reimbursement Manager works in conjunction with the Director of Health Information Management to develop coding in-services and institutional coding policies to ensure that coding policies complement the official coding rules and guidelines.

Duties and Responsibilities:
Performs data quality reviews on inpatient records to validate the ICD-9-CM codes, MS-DRG or AP-DRG, APR-DRG, identify missed secondary diagnoses and procedures, and ensures compliance with all DRG mandates and reporting requirements.
Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and documentation improvement.
Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participates with the planning and development of educational programs directed towards improving documentation.
Creates and monitors inpatient case mix reports and APR-DRG accuracy to identify patterns, trends, and variations in the facility’s frequently assigned DRG reports or specific areas impacting US News and World Report ratings. Once identified, the Clinical Reimbursement Manager evaluates the causes of the change or problems, and takes appropriate steps in collaboration with coding staff, HIM management staff, CDI leadership and the hospital administrative staff.
Demonstrates advanced knowledge about HIS standards of coding and applies to ongoing evaluation of medical record documentation in all facility care settings. To include ICD-9-CM and HCPCS coding Consistently meets established productivity targets for work assignments.
Assists with inpatient coding during staffing vacancies and high volume workflow to assure maintaining a 3 day coding turnaround time.
Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places.
Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
Assists in the review and distribution of coding related information to clinical staff, including CPT-4-CM and ICD-9-CM code changes, medical necessity policies and coding/billing information regarding new. Assists in education and training of all coding team members.
Assists in continuous review and support of revenue cycle with Associate Director of Coding and Compliance.
Participates in education programs to maintain up to date coding skills
Assists in data reporting, i.e. SPARCs, RAC, etc.
Computes, analyzes, and presents reports generated from 3M report writer for internal use and improvement initiatives.
Investigates and acts to resolve outstanding accounts appearing on the discharged not final billed and track reports. Communicates issues to responsible individual and/or department for prompt resolution of unbilled accounts.
Responsible for remaining current with the latest healthcare technology and coding advise through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for outpatient reimbursement and coding.
Assists Associate Director with scheduling, planning and conducting coding in-services for staff members.
Participates in the Studer Service Excellence five pillar programs focusing on excellence in service, quality, people, finance and growth.
Performs other duties as assigned 

HS diploma, Bachelor’s degree preferred.  RHIT, RHIA or equivalent degree or related experience. (All Levels).  At least 3 years of related experience working in an acute care hospital.  Strong foundation in clinical medicine, ICD-9 CM and CPT-4 Coding.  Knowledge of medical terminology.  Excellent knowledge of federal and All-Payer DRG reimbursement methodology.

Strength Through Diversity


The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.


We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care. 

Explore more about this opportunity and how you can help us write a new chapter in our story! 


Who We Are


Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.


Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.


The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 


EOE Minorities/Women/Disabled/Veterans

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