Job Description

Job Title: Fraud, Waste, and Abuse Coding Specialist
Job ID: 678030
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Fraud, Waste & Abuse
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
Are you looking for the next step in your coding career?  Look no further- UPMC is hiring a Coding Specialist for their Fraud, Waste, and Abuse department.  This role is responsible for quality review/monitoring of Health Plan Coding Specialist Staff/or external coding personnel.  The position 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. The role also provides coding related support to internal staff.

This position is located at the US Steel Tower in Pittsburgh.  After training is complete, the Coding Specialist may have the opportunity to work from home.

Responsibilities:
  • Communicate effectively with Risk Adjustment Staff, nurse reviewers and physicians and ancillary departments as necessary to address issues and concerns.
  • Compile and report statistical data to internal and external customers.
  • Completion of special projects including claims and/or coding related audit support.
  • 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.
  • Ensure that all codes are documented for the assignment of a valid and accurate Hierarchical Condition Category (HCC).
  • 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.
  • Provide assistance to other departments as requested.
  • Review the coding of diagnoses and verifying the proper ICD-10-CM 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.
  • Utilize standard coding guidelines and principles and coding clinics to verify that the appropriate ICD-10-CM and CPT codes were assigned including modifiers for correct DRG/APC assignment and accurate reimbursement.

Qualifications

  • Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) or a certified coding program. 
  • Five years of coding experience in a health care setting. 
  • Extensive knowledge of ICD-10 and CPT classifications and coding of diagnoses and procedures is required. 
  • In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required. 
  • The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential. 
  • Excellent written and verbal communication skills are essential. 
  • Proficiency in computer skills required for coding (MARS, Cerner). 
  • Detail oriented individual with excellent organizational skills.  
  • High degree of oral and written communication skills.  
  • Proficiency in Microsoft Office/PC skills. 
  • Traveling may be required as necessary. 
  • EDUCATIONAL/KNOWLEDGE PREFERENCES: 
    • Bachelors Degree or equivalent education/experience.  
    • Three years of claims and/or general auditing experience

Licensure, Certifications, and Clearances:
  • Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT)

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $22.60 to $39.11

Union Position: No

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At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

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