Job Abstract

Job Overview:

The Quality Officer I is responsible for ensuring accuracy and integrity of ICD-10-CM/PCS coding and DRG assignment for inpatient Medicare encounters. This requires critical thinking and a skill set due to the complexity and risk relative to Medicare patients. Quality Officer I must also sustain an excellent organizational average accuracy rate. Adherence to applicable Federal and State Regulations, Compliance Guidelines, and Coding Guidelines set forth by RWJBH, American Hospital Association (AHA) and the American Medical Association (AMA) must be maintained.

Qualifications:

Required:

• Bachelor’s degree or equivalent in experience.

  • 5+ years acute care coding and/or auditing experience with a concentration on inpatient Medicare records is required with a Bachelor’s degree.

  • 9+ years acute coding and/or auditing experience required without a Bachelor’s degree.

• CCS required; ICD-I0-CM/PCS proficiency required.

• Extensive knowledge of ICD-10-CM/PCS and CPT coding, medical terminology, human anatomy and physiology, clinical indicators associated with disease processes and pharmacology is required.

• Knowledge of billing and coding regulations.

Preferred:

• CPC-H, RHIT, RHIA and/or RN also encouraged.

Scheduling Requirements:

• Position is primarily remote with occasional onsite requirement.

Essential Functions:

• Ensures the accuracy and integrity of ICD-10-CM/PCS, CPT coding when applicable and DRG assignment for adherence to Federal and State Regulations and Compliance Guidelines.
• Critically analyzes each inpatient medical record to apply appropriate coding, DRG judgements, SOI, ROM and POA.
• Independently manages SMART pending queues for all acute care RWJBarnabas facilities. Reviews ICD-10-CM/PCS coding and DRG assignment of medical records as “flagged” by SMART.
• Independently manages EPIC SMART WQ’s to assure proper workflow of identified accounts.
• Directs coders with appropriate case-specific recommendations. Educates and coaches coders in the application of coding principles, code assignment and sequencing, DRG assignment and clinical disease processes. Coding advice must be clearly and concisely written with appropriate clinical indicators cited. Additional facilities that may join the System receive the same education and coaching from the Quality Officers to ensure a unified methodology within the RWJBH organization. This results in improved outcomes in DRG assignment, coder education and DNB lag time within all facilities.
• Sustains an excellent organizational average accuracy rate by leveraging advanced knowledge of coding practices leading to exceptional results.
• The Quality Officer’s coding analysis is reviewed by the Coding Specialists on a biannual basis. The consequences of incorrect judgments affecting the DRG may include an increased monitoring, until quality scores of 90% or better for two consecutive months are obtained. The consequences of incorrect coding resulting in erroneous DRGs includes under reporting and/or over reporting. Incorrect coding may result in an incorrect reporting of diagnoses and procedures to the patient’s EHR which may affect the patient’s future care, insurance claims and coverage. When accounts are not reviewed and released in a timely manner, there is a detrimental impact to the reimbursement flow for the facility (DNB).
• Productivity Standards must be met for all Quality Officers. Failure to meet productivity standards will result in progressive disciplinary action.
• Independently monitors SMART queues to ensure all records imported by SMART are reviewed and properly directed, with/or without coding or other recommendations, or released to billing as appropriate and within department accepted timelines.
• Works as a team with other Quality Officers to ensure SMART review goals are met for all RWJBarnabas facilities.
• Reviews Discharge Status, Admission and Discharge Dates, and other related demographic information coded and entered by affiliate staff for accuracy and completeness. Communicates the need for Case Management review to the RWJBarnabas facilities when appropriate.
• Reviews Present on Admission (POA) indicators for all diagnosis coded and entered by coders for accuracy and completeness.
• Independently reports problems with any and all computer system to RWJBarnabas IT&S or SMART helpdesk for resolution.
• Maintains proper computer and written records of all review activity.
• Effectively communicates coding recommendations and rationale to Coding team.
• Performs regulatory coding research as needed.
• May be required to perform other related duties.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.