Clinical Coding Denial Specialist

Job Profile SummaryPosition Summary:
The Clinical Coding Denial Specialist is responsible for reviewing and responding in a timely manner to outpatient coding and procedure focused denials from external payers and their contractors for both facility and professional claims. Works collaboratively with Coding, Revenue Integrity, Patient Financial Services and other department leaders as needed to provide feedback on targeted areas and results of denial activity in order to prevent future claim denials.


Key Responsibilities:
• Intakes, reviews, and responds to external payor audits for RRH facilities related to coding denials. Ensures timely responses are submitted with supporting documentation. Documents decisions throughout the appeal process and tracks cases to resolution. Works collaboratively with Denial Coordinators and HIM Operations to ensure the appeal and supporting documentation is submitted within contractual timeframes.
• Responsibilities include initial review of the denial focus area to determine whether an appeal is warranted.
• Performs post payment reviews where medical necessity is being challenged.
• Responsible for system wide review and appeals on Medicare and Medicaid RAC, PERM, CERTs, etc. audits.
• Prepares and submits cases for independent arbitration.
• Responsible for tracking all denial related information across multiple platforms including denial tracking software, spreadsheets, and Care Connect.
• Assists with tracking and trending outcomes at each level and the overall success of the appeal process.
• Independently manages the review and response for coding-based denials with input from coding leadership if needed. Works collaboratively with the Revenue Integrity, Patient Financial Services, and attending providers to determine if a clinically based appeal is appropriate.
• Maintains standard response templates and documentation of contractual payer response requirements, e.g. levels of appeal and timeframes.
• Work in partnership with the Denials coordinators in tracking, monitoring, and reporting denial related recoupments and payments following the appeals process. Ensures that systems are up to date so that payments can be reconciled by the central billing office.
• Identifies coding trends and clinical focus areas of the external payers/auditors and works collaboratively with the Coding, Revenue Integrity, and Central Business Office to raise awareness, provide education and develop responsive strategies.
• Assists with monitoring related resources and websites to identify current external payor/auditor strategies and focus areas and ensure that up-to-date strategies are in place at both a system and facility level.
• Works closely with Central Business Office, and Coding Leadership to help streamline and improve the denial/appeal process.
• Monitors and responds to the Patient Financial Services email inquiries in a timely manner.
• Processes requests for codes from other departments such as the Care Connect Reporting Team.


Desired Attributes:
Associates degree or higher in a relevant field, including but not limited to: HIM, Nursing, or Billing/Finance preferred.
- Knowledge of Epic preferred
- Practical experience with computerized encoding and grouping software preferred
- Proficient in Microsoft Office applications preferred.


Minimum Qualifications:
Two years of outpatient coding required; five or more years preferred.

EDUCATION:

LICENSES / CERTIFICATIONS: 

PHYSICAL REQUIREMENTS:

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$28.00 - $33.00

CITY:

Rochester

POSTAL CODE:

14617

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.
Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.

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