Coding Denials Resolution Specialist

Responsible for reviewing all post-billed denials (inclusive of coding-related denials) for coding accuracy and appealing them based upon coding expertise and judgment within the Hospital and/or Medical Group partner revenue operations. Serves as part of a team of coding denials resolution specialists 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. 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; also responsible for understanding and resolving Professional Billing HCFA1500 claims or other coding reasons, and processing charge corrections based on medical record reviews, contracts, and regulations as directed by 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/regulations.

• High school diploma or Associate degree in Accounting, Business Administration, or related field, and a minimum of four (4) years of experience within a hospital or clinic environment, health insurance company, managed care organization, or other healthcare 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 typically obtained through a coding certificate program, and at least one (1) year of physician/professional and hospital outpatient coding experience, or a minimum of two (2) years of relevant hospital inpatient coding experience including DRG assignment.
• Must hold one of the following credentials: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC). Certified Professional Medical Auditor (CPMA) will also be considered.
• 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.
• Demonstrates 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.
• Previous experience working with Global Partner vendors is preferred.
   

Physical Demands and Work Environment:

• This position operates in a remote environment that must be a dedicated space ensuring confidentiality and privacy are maintained.
• Frequent communication via Microsoft Teams, email, and phone with colleagues across locations.
• Manual dexterity required to operate a keyboard. Hearing required for extensive phone and Teams meeting communication.
• The remote work environment requires the ability to concentrate, meet deadlines, work on several projects simultaneously, 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.