Coding Denials Resolution Specialist / Coding Team Lead

Responsible for reviewing all post-billed denials (including coding-related denials) for coding accuracy and appealing them based on coding expertise and judgment within Hospital and/or Medical Group partner revenue operations. Serves as part of the coding denials resolution team responsible for identifying and determining root causes of denials. Responsible for using coding knowledge and standard procedures to track appeals through all levels and ensure timely filing as required by payers. Also promotes departmental awareness of coding best practices.

Duties and Responsibilities

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values. 
• Provides detailed understanding or aptitude for resolving denials based on ICD-10-CM diagnosis codes, ICD-10-PCS codes, and CPT-4 procedural codes for UB-04 outpatient or inpatient claims.
• Responsible for understanding and resolving Professional Billing HCFA1500 claims or other coding-related issues, and processing charge corrections based on medical record reviews, contracts, and regulations as directed by the supervisor.
• Interprets data, draws conclusions, and reviews findings with all levels for further review.
• Takes initiative to continuously learn all aspects of the role to support progressive responsibility.
• Maintains a working knowledge of applicable federal, state, and local laws and regulations.

Additional Duties and Responsibilities – Coding Team Lead

• Serves as first-line support for coders, answering questions, troubleshooting issues, and escalating complex cases to the manager.
• Reviews team members’ work for accuracy and compliance, providing coaching and real-time feedback.
• Tracks productivity and quality metrics at the individual and team level and communicates performance trends to leadership.
• Supports onboarding and training of new coders, ensuring consistency in process knowledge and documentation.
• Responsible for monitoring and maintaining assigned leader workqueues.

• High school diploma or Associate degree in Accounting, Business Administration, or related field, and a minimum of four years of experience in a hospital, clinic environment, health insurance company, managed care organization, or healthcare financial service setting; or an equivalent combination of education and experience. Experience in a complex, multi-site environment preferred.
• Comprehensive knowledge of professional/physician diagnostic and procedural coding, typically obtained through a coding certificate program, and at least one year of professional and hospital outpatient coding experience, or a minimum of two years of hospital inpatient coding experience including DRG assignment.
• Must hold one of the following credentials: RHIA, RHIT, CCS, CPC. CPMA will also be considered.
• Experience with NCCI edits, NCDs, LCDs, and outpatient coding guidelines for official coding and reporting.
• Detailed understanding of compliant healthcare billing and collections principles.
• Expertise in medical terminology, disease processes, patient health record content, and the medical record coding process.
• Comfortable operating in a collaborative, shared leadership environment.
• Previous experience working with Global Partner vendors preferred.

Physical Demands and Work Environment

• Remote work environment requiring a dedicated space that ensures confidentiality and privacy.
• Frequent communication via Microsoft Teams, email, and phone with colleagues across locations.
• Manual dexterity required to operate a keyboard; hearing required for phone and Teams communication.
• Ability to concentrate, meet deadlines, work on multiple projects, and adapt to interruptions.
• Must be able to set and manage work priorities independently, adjust to changing demands, and work under potentially stressful conditions with individuals possessing diverse personalities and work styles, including Global Partner vendors.