Coding Denials Specialist
3 days ago
Job Summary:
The Coding Denial Representative is responsible for reviewing the payor's denials and identifying the root cause of
the denials account. The Coding Denial Representative determines if the account is appealable or not.
Coding Denial Representative must understand and comply with the process established by the Federal and State regulations, Payor's specific guidelines, Official Coding Guidelines, and be able to navigate the system properly. The Coding Denial Representative must ensure the confidentiality and
privacy of information.
Essential Functions:
- Performs retrospective (post–discharge/post-service) medical record quality audits to
- determine the appellate potential of claims with denied reimbursement related to Inpatient and
- Outpatient coding data.
- Constructs and documents a succinct and fact-based case to support the appeal, utilizing
- appropriate resources and medical record document(s) to support the appeal. (Resources
- include AHA Official Coding and Reporting Guidelines, CMS guidelines, ICD-10, and CPT
- coding).
- Demonstrates ability to critically think, problem solve, and make independent decisions
- supporting the coding appellate process.
- Demonstrates proficiency in the ability to achieve accuracy and consistency in the selection of
- principal and secondary diagnoses (including MCC and CC) and procedures. Provides
- education/feedback and coding guidance to the client regarding coding cases that did not
- warrant appeal resolution.
- Demonstrates proficiency in the utilization of electronic tools in the medical record
- quality review process, including but not limited to application of coding guidelines; patient
- accounting application; work listing application; visual imaging/scanning application; payor
- websites, electronic medical record, following Conifer's training of Assigned Personnel:
- Conifer's system ACE, Invision, Star, Meditech, EPIC, MedAssets (formerly IMaCs),
- eCARE, Authorization log, InterQual, VI, HPF, as well as competency in Microsoft
- Office.
- Demonstrates basic patient accounting knowledge, i.e., UB04and EOB components,
- adjustments, credits, debits, balance due, patient liability, etc.
- Serves as a resource to non-coding personnel by responding to the clinical team
- questions/consults if needed.
- Will write the appeal letter (and electronically transmit the letter) in the appropriate host
- system: ACE, Invision, Star, Meditech, EPIC, MedAssets, or others as may be applicable.
- Follow the client's operational and compliance policies and procedures, as applicable, and as
- such policies and procedures.
- Perform as a team player.
- Other tasks/functions that may be assigned by the company as per business requirements;
- These may change from time to time to reflect the changing requirements of your position and
- our business.
Education/ Experience:
- Must have PHRN | USRN | PHD License
- Must have 3-4 years of IP coding experience
- CCS Required
- Hybrid Set-up
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