To provide timely clinical and coding review of
claims and claims appeals related to CPT, HCPCS and/or ICD-10 coding, to ensure
accuracy of modifiers, place of service and/or date of service and to make
processing recommendations per established clinical and/or coding criteria/conventions. To provide support and consultation
to various Internal Departments as a Clinical Code Resource and in processing
of memorandums of understanding (MOU).
Perform clinical claims review and evaluate
billed services for coding accuracy and appropriateness while meeting claim
turn around times(TAT) and maintaining unit production goals, utilizing various
resources such as Hill Physicians Guidelines, Health plan policies/guidelines,
Milliman Care Guidelines, ClaimCheck, CPT, Encoder, etc. and obtaining
additional medical information as necessary.
Manage/prioritize claims related issues from
various sources such as electronic queues, e-mail, fax requests, Call Tracker
requests (CTs) and daily claims reports.
Collaborate with designated physician
leaders/Medical Management Teams for clinical support decisions.
Update/modify authorizations according to
review findings and clearly document necessary claims processing
recommendations to ensure proper payment of the claim or claim appeal.
Review retroactive authorization requests
according to Health plan policies/guidelines, Hill Physicians policies and
operational processes, including member history review, Milliman criteria, as
well as obtaining additional information, and collaborating with physician
leaders, designated Case Managers, or Prior Authorizations Nurses when
Provide coverage and support for the MOU
(Memorandum of Understanding) Coordinator as needed: Prepare and coordinate the
MOU process including contacting the rendering provider’s office, negotiating
rates and sending out the agreement letter according to Hill Physicians
policies and operational processes.
Participate in internal workgroups as a
medical/clinical code review expert and complete assigned projects to meet
Provide coding and claims review support to
providers and all interdepartmental staff.
Actively support the Clinical Code Review Unit
audit process and participate in staff education activities and training.
Track and trend claim and authorization
discrepancies with communication to appropriate departments, supervisors and
managers, and assist with provider education as necessary.
Assist interdepartmental staff with
coding/claims review questions/issues & provide education & training as
Other duties and projects as assigned.
Active, unrestricted California licensure: RN,
LVN, RHIT/RHIA, or CPC/CCS/CCS-P certification preferred.
Minimum 3 years clinical nursing experience; or minimum 2 years medical
coding experience with strong understanding of anatomy & physiology and
medical terminology (proof of passing score in A&P/Medical Terminology
Claims review or related managed care
experience, minimum one year required.
of CPT, HCPCS and ICD-10 coding required.
of RBRVS-based and Medi-Cal fee schedules or payment systems required.
Understanding of the National Correct Coding
Initiative and CPT coding rules/standards.
Ability to communicate and work with a variety
of customers, including internal and external physicians, in a professional and
Proficient with various internet resources and
routine software applications, including Microsoft Office. Competence in Excel
Excellent organization, verbal & written
Strong ability to work well independently and
as part of a team.
Hill Physicians is an Equal Opportunity Employer