UPMC Health Plan has an exciting opportunity for a Quality Assurance Coding Specialist in the Operation Risk Integrity department. This is a full time position working Monday through Friday Daylight hours.  This is a remote position, but must be in the Eastern Standard Time Zone to be considered due to business needs.
 

The Quality Assurance Coding Specialist will be responsible for quality review/monitoring of Health Plan Coding Specialist Staff/or external coding personnel. Performs auditing functions including monitoring, coding of diagnosis, reviewing medical record documentation and discharge summaries to determine if appropriate code was assigned to ensure Health Plan compliance with coding standards. Provides coding related support to internal QA/F&A staff.

Responsibilities:

• Review the coding of diagnoses and verifying the proper ICD-9-CM codes were assigned by the HCC Coding Specialist.
• Communicate effectively with Risk Adjustment Staff, nurse reviewers and physicians and ancillary departments as necessary to address issues and concerns.
• Provide assistance to other departments as requested.
• Completion of special projects including claims and/or coding related audit support.
• Utilize standard coding guidelines and principles and coding clinics to verify that the appropriate ICD-9-CM and CPT codes were assigned including modifiers for correct DRG/APC assignment and accurate reimbursement.
• Monitor the assignment of the principal and secondary diagnoses and procedures by thoroughly reviewing all documentation in the medical record utilizing knowledge of anatomy, physiology, medical terminology and pathology.
• Ensure that all codes are documented for the assignment of a valid and accurate Hierarchical Condition Category (HCC).
• Compile and report statistical data to internal and external customers.
• Determine diagnoses that were treated, monitored and evaluated and procedures done during the episode of care to validate that the appropriate codes were assigned by the HCC Coding Specialist.
• Review the discharge summary, history and physical, physician progress notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to accurately assign a diagnosis and / or procedure.