Specialist - Submission

Role Overview

Specialist - Submission at SEHA. This role reviews, abstracts, and analyzes clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

Role Purpose

Own the end-to-end coding process for patient medical records, ensuring accurate code assignment, claim compliance, and timely submission while maintaining alignment with regulatory standards and organizational policies.

Key Responsibilities

Clinical Coding & Analysis

• Review and analyze patient medical records to ensure all applicable patient data is available for coding.
• Abstract pertinent information from patient records and assign relevant codes.
• Allocate appropriate and specific codes from the indexing system and assign codes for completing coding summary of medical records.
• Assign appropriate codes for pre-authorization purposes.
• Ensure accurate coding and sequencing as specified by established coding principles and guidelines, following the clinical coding system.

Evaluation & Documentation Management

• Review and assign appropriate E&M codes based on Clinician's documentation available in medical records to ensure proper reimbursement for the facility.
• Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Contact the department, section, or clinic and obtain copies of additional documentation.
• Validate that encoded information is reported with the most accurate information and regulatory requirements.
• Ensure timely analysis, notification, and completion of medical records as per facility chart completion policies and procedures, regulatory and accreditation standards.

Claims Audit & Reimbursement

• Review and audit medical claims to ensure accuracy, compliance with payer guidelines, coding and billing standards, and organizational policies.
• Identify billing discrepancies and prevent revenue leakage.
• Improve claim quality and support continuous process improvement.
• Review and confirm assigned codes for resubmissions and denials for reimbursement needs pertaining to coding errors.
• Collaborate with coders, billers, physicians, and operational teams to resolve claim-related issues.

Quality Assurance & Compliance

• Assist with the preparation of medical records for quality assurance and medical audit purposes by providing coding data.
• Report defaulters to the Senior Clinical Coding Officer for further actions as per facility policy and procedures.
• Ensure that coding is consistent with all recognized standards.
• Comply consistently with facility policies, procedures, and practices and ensure alignment with SEHA facilities policies.
• Complete and maintain regulatory requirements including licensure and certification and other mandatory training within established timeframes.

Continuous Learning & Professional Development

• Stay current with the clinical coding system through publications, seminars, workshops, continuing education programs, and other changes in the insurance industry.

Qualifications & Experience

• Bachelor Degree in Health Information Management or relevant field, or Diploma with 3 years of additional experience in Healthcare.

Skills & Competencies

Desired Qualifications

• Master degree or equivalent in Health Information Management or relevant field.
• Diploma in relevant field.