PRMO Established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke Primary Care. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Dukeâ€™s reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.
General Description of the Job Class
Coordinate/review the work of vendor outsourcing partners assist with the training and continuing education programs. Code medical records utilizing ICD-10CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement professional charges. Abstract information from medical records following established methods and procedures.
Duties and Responsibilities of this Level
Ensure qualityand quantity of work performed through regular audits and QC for vendor services, specifically in the area of Charge Review Edits and Claims Manager Edits.
Monitor and track outsourcing vendor performance as it pertains to QC and Productivity
Review and research the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10 CM and/ or CPT, HCPCS coding conventions and payer specific coding guidelines.
Develop andassist training, presentations and educational tools for any relevant topic as it relates to continuing education programs on areas of specialization, coding,operational workflow and quality control.
Collaborates with other departments and partners (e.g. Revenue Integrity, QA Team,Compliance Specialist, Intern al Controls, Billing and Collections and Revenue Managers) to ensure coding feedback to outsourcing vendors and team are provided.
Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
Consult with and provide feedback to physicians or department on coding practices andconventions in order to provide detailed coding information. Communicate with clinical, ancillary staff and revenue managers for needed documentation to ensure accurate coding.
Develop and maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-9-CM/ICD-10 CM and CPT-4 coding guidelines to inpatient/outpatient diagnoses and procedures.
Develop and maintain thorough understanding of medical record practices, standards,regulations, Health Care/ Finance Administration (HCFA) and Uniform Billing(UB-04), CMS, and other payer policies and any health care relevant changes.
Develop and maintain a thorough understanding of payer specific guidelines as it pertains to edit review and denial management.
Develop and maintain a thorough understanding of payer specific appeal process
Develop and maintain a thought understanding of CMS and Palmetto Claim Processing Manual including the Smart Edits and Claim Rejection.
Ensure active participation in a team event and departmental activities in the PRMO and DUHS
Ensure compliance to PRMO and DUHS policies and code of conduct
Assist with special projects as required
Medical RecordsCoder II – Vendor Support – PB Edits
This is a progressive coder/auditor position, with opportunity for development and growth, accountable for key strategic vendor education and ensures coding accuracy for the vendor services. The ideal candidate has experience and knowledge in coding/billing, denials, payer guidelines as well as well-developed analytical skills in this area. The position is a forward facing role that will have regular access / communication to our coding vendor partners. Coding certification is required and additional certification for auditing is preferred.
Quality Contro l – (40%)
Review of vendor work to identify erroneous coding patterns and errors specifically in the PB Charge Review and Claims Manager Edits.
Review of vendor work to identify incorrect coding decision and system action
Review of vendor work to identify appeal structure and effectiveness including identifying areas of opportunity to ensure system enhancement and work flow improvement
Providing feedback and education to vendor services to address issue found in the QC process
Monitoring and tracking of QC result
Provide coding process analysis and support for the department as an expert for Outsourcing partner QC team and supervisors
Vendor Education (30%)
o Plan activities aimed at improving the Coding Vendor's quality performance in operations
o Design and implement strategies for enhancing vendor's work quality and increasing productivity.
o Evaluate effectiveness of improvement strategy through sustained tracking and monitoring of vendor's related WQ.
o Reporting of vendor specific trends and issues to upper management
o Performing actual coding function to various coding WQs (i.e. PB Charge Review Edits, Claims Manager Edits and Denials)
o Performing necessary research and investigation to resolve coding related issues and enhancement of the business process associated with job functions and responsibilities
o Maintaining coding skill by continuing education and keeping abreast to regulatory healthcare related changes and payers rule update
High school diploma required.
RHIA certification- no experience required RHIT certification- no experience required CCS certification- one year of coding experience required CPC or HCS-D certification- two years of coding experience required
Degrees, Licensures, Certifications
Must hold one of the following active/current certifications: Registered Health Information Administrator (RHIA) Hospital Coding Registered Health Information Technician (RHIT) Hospital Coding Certified Coding Specialist (CCS) Hospital Coding Certified Professional Coder (CPC) Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.