Loretto Management Corporation

  • Specialist, Compliance Reimbursement - PACE

    PACE - 1
    Regular Full-Time
    Weekends Required?
  • Overview

    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.


    • Conducts initial reviews of various medical record documentation to ensure the capture of all appropriate diagnoses/procedures related to reimbursement and compliance standards.
    • Routinely reviews medical record information and coding to identify appropriateness based on CMS HCC categories.
    • Ensures the accuracy, completeness, specificity and appropriateness of diagnosis information.
    • Verifies and ensures the accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered.
    • Identifies trends/problems in medical documentation and recommends solutions to the Health Information Director/designee.
    • Provides education and training regarding provider documentation via daily interaction with providers and other suitable training modalities to ensure capture of all applicable diagnoses/procedures related to reimbursement and compliance standards. Writes monthly education newsletters. Reports any trends and/or issues to the Health Information Director or designee.
    • Identifies medical services provided but not adequately documented in medical record. Advises supervisor and clinicians of deficiencies to ensure accuracy, completeness and capture of maximum reimbursement.
    • Prepares provider profiles on a monthly basis, prepares utilization and various statistical reports. In collaboration with Health Information Director assists in analysis as appropriate. Acts as back up person for completion of risk adjustment reports.
    • 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.


    • Minimum 2–3 years of coding experience necessary.
    • A combination of outpatient and inpatient (hospital setting) preferred.
    • Certified Coding Specialist (CCS/CCS-P), Certified Procedural Coder (CPC/CPC-H) certification, or Associates Degree with RHIT credentials required. Proficient with ICD-10 coding; understanding of DRG systems and other reimbursement methodologies.
    • Proficient with MS Office and able to learn new software rapidly.
    • Prior experience with Electronic Medical Records highly desirable. Knowledge and experience in managed care environment highly desirable.
    • Attention to detail and accurate input skills required. Strong organizational and analytical skills with ability to prioritize work. Strong written and verbal communication skills; strong analytical, organizational and time management skills required. Per Job Description.


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