Quality Coding Specialist

Position Summary/Position

Under the direction of the Quality Systems Leadership team, the Quality Coding Specialist is responsible for assessing Provider practices in their coding and billing processes, with the goal of identifying areas of opportunity for improvement in quality reporting and data capture. The Quality Coding Specialist must have a strong background in medical record documentation standards, provider billing rules in Medi-Cal and appropriate coding practices. The Quality Coding Specialist will work directly with provider offices to help improve coding, documentation, and billing practices with the goal of improving data accuracy and completeness to impact quality measurement reporting at the Plan level.
The Quality Coding Specialist will be a resource and liaison between IEHP and network Providers to support the submission of accurate and timely medical claims and encounters with the intentional focus on quality measure performance. The Quality Coding Specialist must effectively communicate with key stakeholders in any assigned quality improvement project, including external providers and internal health plan staff and leaders.  The Quality Coding Specialist must be a proactive team player who works independently in external environments and who builds rapport with diverse Providers and their office staff.  This role will require frequent travel within the Inland Empire.

Major Functions (Duties and Responsibilities)

1. Work collaboratively as part of a regional quality improvement team and as an individual contributor supporting quality measure improvement among IEHP’s network Providers. Quality measures of focus for this role include Healthcare Effectiveness Data and Information Set (HEDIS), California Department of Healthcare Services (DHCS) Managed Care Accountability Set (MCAS), Medicare CMS Stars, and Covered CA CMS Quality Rating System.
2. Identify primary care provider (PCP) offices that would benefit from billing and coding training based on assessments of billing and coding patterns and impacts on health plan quality measure performance.  
3. Educate individual Providers and their office staff on how to improve their billing and coding practices to ensure all rendered services are appropriately documented and submitted to IEHP in support of quality measure performance.
4. Develop comprehensive, Provider-specific recommendations to improve billing practices.
5. Train Providers on IEHP’s Provider incentive programs and billing requirements, as needed. 
6. Act as coding resource for Internal IEHP teams and Provider offices on appropriate coding for quality measure performance. Collaborate with Providers, office staff, and IEHP Team Members on a wide range of billing education efforts.
7. Conduct Provider chart audits and assess and interpret whether the billing and coding submitted was properly assigned based upon review of the medical record documentation and application of billing and coding guidelines.
8. Identify potential billing and coding gaps through clinical documentation where services are documented but not properly coded.
9. Rely upon independent judgement and decision making while at a provider site, whether conducting an audit or providing training and education, both from historical and/or real time data.
10. Effectively field questions and concerns from Provider offices and offer solutions that support IEHP guidelines. 
11. Maintain the strictest confidentiality based on HIPAA guidelines. 
12. Maintain current knowledge and understanding of Provider-based industry standard billing and coding practices.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

At least three (3) years of experience with medical claims processing, medical billing and coding with a primary care provider, medical group, or health plan/payor.

Preferred Experience

Education Qualifications

High school diploma or GED required. 

Preferred Education

Professional Certification

AHIMA or AAPC Certified Coding required.
One of the following certifications is preferred: Certified Professional Coder (CPC), Certified Coding Specialist (CCS-P), Certified Outpatient Coder (COC), or Certified Coding Associate (CCA).

Professional Licenses

Drivers License Required

Knowledge Requirement

Advanced knowledge of medical coding and billing systems and regulatory requirements for outpatient medical settings (physician offices, group practices, or multi-specialty centers). Proficiency in use of CPT, HCPCS Level II, ICD-10 CM coding systems.

Skills Requirement

Excellent interpersonal/communication skills. Requires critical thinking skills. Strong organizational skills and computer proficient. Requires general knowledge of Microsoft Access, Word, and Excel.

Abilities Requirement

Ability to:
- Demonstrate a high level of patience and respect.
- Communicate effectively verbally and in writing.
- Work independently to complete cross-functional projects.
- Establish and maintain effective and cooperative working relationships with IEHP staff and IEHP Providers. 
- Handle multiple projects, set priorities, and meet deadlines.
- Gather and analyze data in a detailed and highly organized manner. 
- Be trustworthy and reliable. 
- Quickly learn new tools, as needed.
- Have a high degree of attention to detail and demonstrate good time management.
- Be a strong team player and proactive problem solver capable of accomplishing program goals.
- Demonstrate maturity and soundness of judgment when working with physician offices to achieve quality goals.  
- Maintain Member confidentiality.
- A high degree of patience. 

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus. Position requires frequent travel to off-site network Provider practices and community-based organizations.  Performance of major duties will be carried out within off-site locations.  

Work Model Location

Physical Requirements