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Roles & Responsibilities:
The Clinical Reimbursement Manager is responsible for performing quality reviews on medical records to validate the ICD-9-CM, ICD-10 CM and PCS 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 , ICD-10 CM and PCS coding 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:
1. Performs coding compliant reviews on inpatient records to validate the ICD-10-CM , PCS codes, MS-DRG or AP-DRG, APR-DRG assignment. Identifies missed revenue opportunities and ensures compliance with all coding guidelines and Grouper assignments.
2. 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.
3. 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.
4. Initiates physician queries for clarification of documentation in the medical record to achieve accurate code assignment.
5. Consistently meets established productivity standards for quality and quantity for daily work assignments.
6. 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.
7. 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.
8. Assists in the review and distribution of coding related information to clinical staff code changes, medical necessity policies and coding/billing information regarding new procedures and devices.
9. Assists in education and training of all coding team members.
10. Assists in continuous review and support of revenue cycle with Director and Associate Director of DRG Validation
11. Participates in education programs to maintain up to date coding skills
12. Assists in data reporting, i.e. SPARCs, RAC, etc.
13. Investigates and acts to resolve outstanding accounts appearing on the discharged not final billed, track reports and committee request for validation. Communicates issues to responsible individual and/or department for prompt resolution of unbilled accounts.
14. 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 reimbursement and coding.
15. Performs other duties as assigned
See General skills below:
• Strong foundation in clinical medicine, ICD-9 CM, ICD-10-CM, PCS Coding.
• Knowledge of medical terminology.
• Excellent knowledge of federal and All-Payer DRG reimbursement methodology.
• Must be detail oriented with good verbal, written, communication, interpersonal and customer friendly skills,
• Ability to work under pressure with time constraints.
• Must be able to understand and follow written and verbal instruction.
• Must have the ability to organize multiple priorities and make independent decisions. Must demonstrate initiative and ability to work with physicians and other healthcare providers.
• The team member has access to patient medical information, involved in ensuring the integrity of the legal medical record and must strictly uphold patient confidentiality
Requirements for Position
Required CCS certification.
RHIT, RHIA or equivalent degree or related experience preferred.
3- 5 years of related experience, working in acute care hospital for levels 1, 2 or 3 respectively.
Strength Through Diversity
The Mount Sinai Health System believes that diversity and inclusion 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 healthcare delivery together.
We work hard to recruit and retain the best people, and to create a welcoming, nurturing work environment where you have the opportunity and support to develop professionally. We share the belief that all employees, regardless of job title or expertise, have 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 hospitals, including Mount Sinai Beth Israel, Mount Sinai 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.