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Coding Denials Specialist

Company: CHRISTUS Health
Location: Tyler
Posted on: September 6, 2020

Job Description:

Job Description: Description Summary: This position shall perform the execution of financial, coding, billing compliance, appeals, operational and investigative reviews to ensure the reliability and integrity of information, compliance with policies and regulations, the safeguarding of assets, the economical and efficient use of resources, and established operational goals and objectives of CHRISTUS Trinity Clinic. Responsible for validating coding discrepancies for all assigned pre-billed rejections, and denied professional service claims. Provide feedback to providers to improve clinical documentation and facilitate ongoing documentation improvement. Responsible for performing appeals for CTC for professional services as deemed necessary. Responsible for monitoring denial work queues within EPIC to ensure timely appeal deadlines are met. Must have the ability to understand and apply critical thinking skills to ascertain the root cause for the denial. Must ensure timely, accurate and thorough appeals for all accounts assigned. Participate and/or facilitate a denial management team using a multi-disciplinary approach with staff from the business Office, clinics and outpatient departments as deemed necessary. All team members are expected to be knowledgeable and compliant with CHRISTUS Trinity Clinic's values of compassion, dignity', excellence, integrity and teamwork. Identify the major reasons for the denial-roots causes (dx, procedure codes, etc.). Work collaboratively with Coding Integrity. Review account denial audits results and perform trend analyses to identify patterns and variations in coding denials and practices. Create a tracking report to identify denial trends. Must be able to maintain open communication with CTC physician practice to facilitate denial/appeals review process. Utilize EHR system to review and validate coding submission on professional and hospital claims. Monitors appeals and other metrics as defined by director/admin to ensure performance guidelines are being met. Maintains data and assists with identifying patterns of denial activity. Monitors payer response to appeal activity. Interacts with Utilization Management and other clinical departments to coordinate information for preparation of appeals. Acts as a resource in regards to denials, appeals process and provides assistance and guidance as necessary. Submit appeals correspondence to third party payors when claim denied for coding reasons. Process per-billing clinical edits and post-billing denials within department guidelines and timeframes. Evaluates and adheres to clinical and billing policies, guidelines and regulations of both commercial and governmental payers. Also, appeals denials or instructs the resubmission of claims based on compliant medical record documentation and hospital policies and procedures Review coding and/or denials for maximum reimbursement from third party payors Participates in departmental presentations to include training, denials and appeals reports to management as necessary. Provide feedback to physicians and management in a timely and professional manner. Provide coding and billing support, training and education to clinical and administrative staff to CTC physician practices. Maintains data and assists with identifying patterns of denial activity. Monitors payer response to appeal activity. Interacts with Utilization Management and Other clinical departments to coordinate information for preparation of appeals. May need to prepare appeal letters and provide payor's with appropriate clinical documentation as needed. Assesses the need for formal appeals of all clinical denials including but not limited to preauthorization of diagnostic and surgical procedures, admissions, and for retroactive recovery reviews regarding medical necessity and limited billing compliance. Prepares appeal letters that are specific, concise, and conclusive; providing payers with appropriate clinical documentation as needed. Adheres to all appeal timelines as prescribed by payer agreements. Assesses the need for formal appeals of all clinical denials including but not limited to preauthorization of diagnostic and surgical procedures, admissions, and for retroactive recovery reviews regarding medical necessity and limited billing compliance. Maintain knowledge of managed care, commercial, governmental and Medicare payors' clinical documentation, coding and billing guidelines. Utilize resources and time to meet performance and productivity goals. Performs any and all other duties as assigned. Requirements: * Minimum requirements: Associate/Bachelor Degree in Business/Healthcare or 5-7 years of direct coding and denials experience * 3-5 years of healthcare, clinical appeals/denials, coding, billing, CPT and HCPCS or combination of applicable experience and education; Or auditing experience preferred. * Denials, Appeals, Coding, Billing and Follow-up * Must be able to think analytically, independently, and objectively. * Medical termin

Keywords: CHRISTUS Health, Tyler , Coding Denials Specialist, Other , Tyler, Texas

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