Deloitte | India Offices of the US

Deloitte’s Risk & Financial Advisory provides you an opportunity to gain valuable hands-on experience working alongside leading professionals across diverse industries while building your professional skills in a variety of project experiences. Our Deloitte Risk & Financial Advisory practice helps organizations effectively navigate business risks and opportunities—from strategic, reputation, and financial risks to operational, cyber, and regulatory risks—to gain competitive advantage. We apply our experience in ongoing business operations and corporate lifecycle events to help clients become stronger and more resilient. Our market-leading team’s help clients embrace complexity to accelerate performance, disrupt through innovation, and lead in their industries.

As a professional in our Regulatory Healthcare Practice, you will have the opportunity to work on multiple projects leveraging your education and prior work experience to help our clients more confidently make decisions to drive performance. You will help our clients embrace change, grow their business, accelerate performance, and navigate periods of crisis or controversy and emerge resilient.

Projects may be aligned to the following areas and include:

• Operational Improvement: For business process that include significant regulatory requirements, you will improve efficiency and business outcomes by leverage process improvement and operating model evolution.

• Clinical Payments Optimization: Assisting clients by validating that payments for clinical healthcare services comply with regulatory and contractual requirements while also determining that payments are appropriate for the type and level of care provided.

• Regulatory Response: Supporting clients with their most pressing regulatory and operational challenges. Helping them to identify, remediate, monitor, and manage enterprise risks and create value through implementing a compliant, resilient enterprise. Includes helping clients manage and respond to internal and external investigations, regulatory concerns and other business controversy.

Conducts coding and billing compliance reviews on medical records to validate the ICD-10-CM and ICD-10-PCS codes, CPT and HCPCS codes for various specialty (including but not limited to Inpatient, outpatient, professional and Medicare advantage setting). The review of the medical documentation is conducted to identify additional missed provider documentation clarifications and/or missed coding opportunities. The professional will utilize the following resources to perform the reviews (not inclusive): The Official Coding Guidelines, ICD-10-CM/PCS, CPT and HCPCs coding guidelines, Federal and State regulations, the American Hospital Association (AHA) coding guidelines including the Coding Clinic and American Medical Association’s (AMA) CPT Assistant publications and American Health Information Association (AHIMA) compliant query guidelines.

General

• Maintain knowledge of coding and billing requirements and regulatory changes

• Maintains current with the Center for Medicare and Medicaid Services (CMS) coding, documentation guidelines, AHA Coding Clinics and AMA’s CPT Assistant and clinical documentation query protocols

• Reviews and research coding and billing related industry rules and standards

• Provides written, detailed rationale and supporting evidence for recommendations on review findings

• Identifies training needs and delivers educational feedback to coding staff regarding review findings

• Ability to effectively communicate verbally and written with stakeholders (internal / external)

• Identifies documentation improvement opportunities that impact coding accuracy

• Quality check of claims adjudication and payments

• Maintain quality and quantity standards as defined by Deloitte

• Tracking and reporting of assigned tasks for internal and external stakeholders

• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and monitors coding staff for violations and reports to Manager when areas of concern are identified

• Identifies and reports any coding or coding related compliance trends or issues to leadership immediately

• Performs other duties as assigned including training/mentoring of new staff and performing research related to special projects

• Maintains coding credentials through ongoing continue education

Outpatient coding reviews

• Performs coding and billing quality reviews on hospital outpatient records to validate the medical record documentation support the ICD-10-CM, CPT and HCPCS, modifiers as applicable and appropriate APC assignment submitted on the claim. Responsible for the coding validation and data capture for the following (not inclusive)

o Diagnoses – primary and secondary

? Capture of chronic conditions for hierarchical condition categories (HCC), if applicable

o CPT / HCPCS procedures and/or services (i.e., medications)

o Modifiers

o If applicable, medical necessity per local review policies (LRPs), payer specific requirements

o Appropriate APC assignments

• Identifies missed documentation query opportunities to further clarify documentation. Provides appropriate clinical parameters in recommendation to support the missed query opportunity

• Evaluates the appropriateness and compliance of coder generated clinical documentation queries

• Identifies missed coding opportunities that would impact the APC assignment or to support medical necessity

• Validate the payments as per the specialty specific billing rules

Professional coding reviews

• Performs coding and billing quality reviews on professional encounters to validate the medical record documentation supports the ICD-10-CM, CPT and HCPCS, and modifiers, as applicable, are appropriately submitted on the claim. Responsible for the coding validation and data capture for the following (not inclusive)

o Diagnoses – primary and secondary

? Capture of chronic conditions for hierarchical condition categories (HCC), if applicable

o Evaluation and management (E/M) level assignment

o CPT / HCPCS procedures and/or services (i.e., medications)

o Modifiers

o If applicable, medical necessity per local review policies (LRPs), payer specific requirements

• Identifies missed documentation query opportunities to further clarify documentation. Provides appropriate clinical parameters in recommendation to support the missed query opportunity

• Evaluates the appropriateness and compliance of coder generated clinical documentation queries

• Identifies missed coding opportunities that would impact the E/M levels, additional procedures, HCCs or support medical necessity

• Validate the payments as per the specialty specific billing rules

Required Candidate profile

• Must have worked on coding and billing domains (i.e., IP, hospital outpatient, emergency department (ED), ambulatory surgery, professional coding, HCC, Outpatient etc.)

• Comprehensive knowledge on US health care industry, Institutional and Professional Claims

• Subject matter expert and analyze medical billing as per Payer, State and CMS guidelines

• In-Depth knowledge of various billing rules OPPS, MPFS etc.

• Expertise in complex clinical coding/reviewing assignments, difficult investigations and highly visible issues

• Thorough knowledge of payment rules hierarchy, fee schedule configuration and their impact on payment

• Excellent organizational skills with ability to trend and track audit findings effectively.

• Superior skills to effectively communicate and negotiate across the business and external health care environment

• Demonstrate ability to interact effectively with clients including providers and internal stakeholders

• Must be a dependable and reliable player, able to work independently and as part of a goal-oriented team with a positive attitude

• Must have strong analytical, reasoning and organizational skills

• Must have experience working on multiple EMR systems including Cerner, Allscripts, MDAudit, Meditech, etc.

• Hands-on experience in any of the Encoder tools specific to Hospital coding such as Epic, 3M, Triode, etc.

• 5+ years of experience in audit of complex outpatient, hospital outpatient and professional coding and US healthcare claims

• Must hold a coding certification from American Health Information Association (AHIMA) and/or from American Academy of Professional Coders (AAPC) such as a CCS, CPC, CIC etc.

• Experience designing, implementing, and operating risk management and compliance activities

• Experience participating in risk, quality and compliance transformational programs preferred

• Experience leveraging data and analytics to enhance risk management, quality, and compliance

• Prior consulting experience is preferred

• A graduate from field of medicine or allied healthcare subject is preferred

• Good understanding of US healthcare

• Expert in performing coding audits of hospital inpatient, outpatient and/or professional claims

• Strong understanding of CMS payment policies and provider contracts

• Proficient in healthcare reimbursement methodologies

• Good analytical and communication skills

• Requires exceptional critical thinking, communication skills and a strong clinical knowledge base

• Must possess effective interpersonal skills in order to interact effectively with client

• Must possess knowledge of a wide range of specialized coding disciplines, including a strong knowledge base in anatomy and physiology, pathophysiology, and pharmacology; and knowledge of the CMS Official Coding Guidelines, AHA Coding Clinic and AHIMA Query Practice Brief guidelines.

• Requires basic computer word processing skills (e.g., formatting, editing, printing, composing email, internet searches, etc.) to be able to successfully navigate through an electronic medical record using a computer

• Effectively disseminate client/coding updates to the team in an individualistic and understandable manner

• Effectively identify and escalate areas of concern or training needs independently

• Requires the ability to read, write and speak effectively in English

• Proficiency in verbal and written communication skills essential to interacting with clients and teams including presentation skills (MS Power Point, MS Visio)

• Advanced proficiency with tools like Excel