Responsible for reviewing all post-billed denials (inclusive of coding-related denials) for coding accuracy and appealing them based upon coding expertise and coding judgment within the Hospital and/or Medical Group revenue operations ($3-5B NPR) of a Patient Business Services (PBS) center. Serves as part of a team of coding payment resolution colleagues at a PBS location responsible for identifying and determining root causes of denials. Responsible for leveraging coding knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by payers. in addition to promoting departmental awareness of coding best practices. This position reports directly to the Supervisor Clinical/Coding Payment Resolution.
Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
Provides detailed understanding or aptitude for resolving denials based on ICD-10-CM diagnosis codes, HCPCS, Modifiers and CPT-4 procedural codes for CMS-1500 outpatient or inpatient claims, or other coding reasons and processing charge corrections based on medical record reviews, contracts, regulations as directed by the Supervisor Clinical / Coding Payment Resolution.
Interprets data, draws conclusions, and reviews findings with all level of Payment Resolution Specialist for further review.
Takes initiative to continuously learn all aspects of Payment Resolution Specialist role to support progressive responsibility.
Other duties as needed and assigned by the Supervisor Clinical / Coding Payment Resolution.
Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
High school diploma or Associate degree in Accounting or Business Administration or related field, and a minimum of four (4) years' experience within a hospital or clinic environment, a health insurance company, managed care organization or other health care financial service setting, performing medical claims processing, financial counseling, financial clearance, accounting or customer service activities or an equivalent combination of education and experience. Experience in a complex, multi-site environment preferred.
Must possess comprehensive knowledge of professional/physician diagnostic and procedural coding, as normally obtained through a coding certificate program and least two (2) years of physician/professional or hospital outpatient coding experience.
Must be a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or coding credential of a Certified Coding Specialist (CCS) or Certified Professional Coder (CPC).
Must have experience with National Correct Coding Initiative edits (NCCI), National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Outpatient coding guidelines for official coding and reporting.
Possesses detailed understanding of principles, methods, and techniques related to compliant healthcare billing/collections.
Possesses expertise in medical terminology, disease processes, patient health record content and the medical record coding process.
Must be comfortable operating in a collaborative, shared leadership environment.
Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
This position operates in a typical office environment. The area is well lit, temperature controlled and free from hazards.
Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues.
Manual dexterity is needed to operate a keyboard. Hearing is needed for extensive telephone and in person communication.
The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions.
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
Must possess the ability to comply with Trinity Health policies and procedures.
This is a remote position.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
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