Coding Denials Specialist - Clinical Practice Services

Summary

The Coding Denials Specialist performs advanced level work related to coding denials management. The individual is responsible for resolving coding claim edits, coding-related claim denials & coding correspondence, monitoring for trends and assist in the analysis, development, and implementation of solutions to minimize avoidable denials and adjustments.

All remote work must be performed within one of the MCW registered payroll states, which currently includes: WI, AL, AZ, DE, FL, GA, IN, MD, MI, MN, MO, NC, TN, TX, & UT.

Primary Responsibilities

Research payer denials related to coding, documentation, referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.

Conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is needed.

Writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through outcome.

Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as MCW/CPS and compliance policies and procedures.

Collaborate with the prior authorization team to obtain retro-authorizations in accordance with payor requirements in response to authorization denials and expected denials.

Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.

Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.

Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.

Identify opportunities for process improvement and actively participate in process improvement initiatives.

Other duties as assigned.

Knowledge – Skills – Abilities

Knowledge of payer policies and claims requirements.

Advanced knowledge of CPT, ICD-10 coding, payer and governmental policies.

Proficiency with EMR’s (EPIC) and Microsoft Office. Focus on continuous process improvement.  Ability to react to frequent changes in duties and volume of work.

Effective communication skills and writing capabilities / efficiencies.

Ability to manage multiple tasks with ease and efficiency.

Effective interpersonal skills, including the ability to promote teamwork, strong problem-solving skills.

Qualifications

• Minimum Required Education:  High school diploma
• Minimum Required Experience: Five (5) years of experience in a health care setting, working in coding and/or reimbursement follow up.
• Required Certification/Licensure(s):  Certified professional coder (CCS-P, CPC, or CCA) and/or health information management credential (RHIT or RHIA).
• Preferred Education:  Bachelor’s degree in business, health care management, or related fields.
• Preferred Experience:  Five+ (5+) years of coding and/or reimbursement follow up experience in professional revenue cycle operations for large, multispecialty group practices and/or academic medical centers.
• Why MCW?
• Outstanding Healthcare Coverage, including but not limited to Health, Vision, and Dental. Along with Flexible Spending options
• 403B Retirement Package
• Competitive Vacation and Paid Holidays offered
• Tuition Reimbursement
• Paid Parental Leave
• Employee & Family Assistance Program (EFAP)
• Pet Insurance
• On campus Fitness Facility, offering onsite classes
• Additional discounted rates on items such as: Select cell phone plans, local fitness facilities, Milwaukee recreation and entertainment etc.
• For a brief overview of our benefits see: Benefits Overview
• For a full list of positions see: MCW Careers
• At MCW all of our endeavors, from our internal operations to our interactions with our partners, are driven by our shared organizational values: Caring – Collaborative – Curiosity – Inclusive – Integrity – Respect. We are committed to fostering an inclusive environment that values diversity in backgrounds, experiences, and perspectives through merit-based processes and in alignment with all applicable laws. We believe that embracing human differences is critical to realize our vision of a healthier world, and we recognize that a healthy and thriving community starts from within. Our values define who we are, what we stand for and how we conduct ourselves at MCW. If you believe in embracing individuality and working together according to these principles to improve health for all, then MCW is the place for you. For more information, please visit our institutional website .
• MCW as an Equal Opportunity Employer and Commitment to Non-Discrimination: The Medical College of Wisconsin (MCW) is an Equal Opportunity Employer. We are committed to fostering an inclusive community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the MCW community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic.