Pro Fee Quality Reviewer
- Virtual, United States
- Client Services
Guidehouse is a leading global provider of consulting services to the public sector and commercial markets, with broad capabilities in management, technology, and risk consulting. By combining our public and private sector expertise, we help clients address their most complex challenges and navigate significant regulatory pressures focusing on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that help our clients outwit complexity and position them for future growth and success. The company has more than 12,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies.
The Remote Pro Fee – Coding Quality Reviewer shall report directly to the Quality Review Supervisor and will be responsible for accessing and reviewing the medical record documentation, coding and abstracting accuracy as performed by the Guidehouse coding team by utilizing ICD-10 CM, CPT and HCPCS coding classification systems. Review of patient records will be conducted via facility EMR, scanning technology or other established method. This position will perform any and all related job duties as assigned.
Duties and Responsibilities:
- Ensure 5% coding quality review (or percentage stipulated in client contract) of each coder’s work is conducted monthly for those facilities the reviewer is assigned. Coding quality review will be conducted to identify abstracting, ICD-10-CM, CPT, modifier, and HCPCS coding errors for codes assigned by the coding team (see quality review policies for review details).
- Reviewer will run coder productivity reports (where applicable) to pull random sample accounts for review and to ensure review percentages are met per facility contract.
- Review coding and abstracting on all patient types assigned for review to include the following: inpatient, ambulatory surgery, ER, clinic, diagnostics and evaluation and management levels to assure 95% coder accuracy (or accuracy percentage as stipulated by client contract).
- Become familiar with any facility specific coding guidelines and know where to access on the Navigant portal.
- Required to read all Coding Clinic and CPT Assistant updates and stay abreast of all new coding guidelines.
- Ensure code recommendations are supported with AHA Coding guidelines, Coding Clinics, CPT Assistant and/or other official coding references.
- Perform chart reviews and coding recommendation notifications (to ensure appropriate turnaround times) to coding team in a timely manner (same day review conducted).
- Enters review findings daily for each account reviewed in quality review software or no less than within 24 hours of conducting the review.
- Communicates in a professional, non-threatening mentorship manner with the coding team in coding quality recommendation discussions.
- Follows review escalation policy when coder/review disagreements occur (see quality review policy/procedures).
- Notify VP of Quality when coding risk areas and error trends are identified for a specific facility and/or coder.
- Assist Coders in answering coding/abstracting questions resulting from the quality reviews.
- Reviews monthly and quarterly coder quality reports and performs intensification reviews for Coders who fall below the stipulated accuracy rate as part of the corrective action plan.
- Maintain a working knowledge of ICD-10-CM and CPT coding principles, governmental regulations, official coding guidelines, and third-party requirements regarding documentation and billing.
- Ability to maintain average review productivity standards as follows:
- Emergency Department (without E/M): 7 charts per hour
- Emergency Department with E/M: 4 charts per hour
- Diagnostics: 12-15 charts per hour
- Surgeries (any service line): 3-4 charts per hour
- Pro Fee Evaluation/Management Level (any setting or service line without procedure): 5 charts per hour
- Pro Fee Evaluation/Management Level (any setting or service line with procedure (major procedure): 3 per hour
- Claim Edit Review: 10-15 per hour
- Complete review activity summary daily (productivity summary) for each facility and submit to QC Supervisor and Director on a weekly basis (utilized to calculate quality review FTEs assigned to each facility).
- Review and be familiar with the annual review criteria standards as well as DRG review calendar (if appropriate to assignment).
- Assist as needed in the review of external coding audit company findings and formulates a response to be used in the defense of the codes assigned.
- Participates in client conference calls and mandatory monthly quality team stand-up calls. Responsible to review the minutes of monthly quality stand up calls if not able to dial into the conference call (minutes are posted on the portal).
- Provide company support for the creation, maintenance and ongoing operation of an efficient and accurate Quality Improvement Plan that is compliant with Local, State, and Federal Government Regulations.
- Work with the Coding Solutions Division to provide on-going coding education resulting from the Quality Reviews. This will involve direct one-on-one correspondence between the coder and reviewer.
- Maintain open lines of communication serving as a liaison between client, Coders, and Coding Solutions Division to ensure that all parties are kept up to date on specific hospital guidelines/policies.
- Participate in company Coding Solutions Division Meetings as requested.
- Reviewer must be able to work independently while maintaining specific productivity standards.
- Basic computer skills are needed to handle connection issues, downloads and to review specific programs.
- Reviewer downtime must be reported immediately to the IQC Supervisor and Director to ensure adequate work flow.
- Access to the facility system or any other system that prohibits you from completing your work assignment should be reported immediately to the IQC Supervisor and Director and Guidehouse support help desk (via phone and/or email notification with a copy to the QC Supervisor/Director)
- Reviewers must maintain their current professional credentials while working for Guidehouse.
- Reviewers are responsible for maintaining HIPAA compliant work stations (reference HIPAA work station policy).
- Reviewers are responsible for maintaining patient privacy at all times (reference company handbook policy).
- Reviewers are responsible for signing a confidentiality statement.
- It is the responsibility of each reviewer to review and adhere to the coding division policy and procedure manual content.
- Works well with other members of the facilities coding and billing team to insure maximum efficiency and reimbursement for properly documented services.
- Communication in emails should be professional and collaborative at all times (reference e-mail policy).
- Must hold one of the following credentials: (CPC, CPMA, CCS-P).
- Three years of previous coding / review experience.
- Must have experience with: multispecialty E&M Coding and Auditing, Multispecialty Surgery Coding and Auditing with an emphasis in Orthopedics and General Surgery
- Abide by all client policies and procedures.
- Abide by all Guidehouse policies and procedures.
- Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
Information System Requirements:
- Computer and monitors provided by Guidehouse.
- Internet Access with DSL or high-speed connectivity.
- Remote office location that meets HIPAA privacy requirements.
- The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described.The salary range for this role is $38.00 – $41.00 , may vary based on experience and location.
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.
Rewards and Benefits
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid Holidays
- Position may be eligible for a discretionary variable incentive bonus
- Parental Leave and Adoption Assistance
- 401(k) Retirement Plan
- Basic Life & Supplemental Life
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach