Under the general direction and supervision of the Health Information Director/Designee, the Compliance Reimbursement Specialist is responsible for analyzing documented clinical data to identify cases where additional provider documentation is needed to better reflect the patient’s clinical picture, severity of illness, etc. In addition, the Specialist will identify, collect, assess, monitor and review documentation and encounter coding as it pertains to Clinical Coding Categories to ensure proper Hierarchical Category Conditions (HCC) assignment identifying the Risk Factors associated with the underlying conditions based on clinical documentation. PACE CNY is seeking to identify coding issues and deal with them in a timely manner while educating providers and their staff on how to prevent future issues.
Monitors compliance with procedures relevant to clinical data management. Conducts monthly audits to monitor for the accuracy of clinical coding by PACE CNY providers and outside providers via hospital bills, etc. as part of the PACE CNY’s compliance program.