The Physician Coding Denials Specialist performs appropriate efforts to ensure receipt of expected reimbursement for services provided by the Physician. Reviews and analyzes medical records and coding guidelines to formulate coding arguments for appeals and/or coding guidance for potential re-bills. Maintains a working knowledge and stays abreast of ICD diagnosis codes, CPT physician service codes, coding principles, modifier usage, medical terminology, governmental regulations, protocols and third-party payer requirements pertaining to billing, coding, and documentation. The Physician Coding Denials Specialist will also handle audit-related and compliance responsibilities. Additionally, this position will actively manage, maintain and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials. This position requires anticipating and responding to a wide variety of issues/concerns and works independently to plan, schedule and organize activities that directly impact Physician reimbursement. This position will support change management by tracking and communicating trends and root cause to support future prevention with internal customers and stakeholders as well as with payers and third parties. This role is key to securing reimbursement and minimizing avoidable write-off’s.

• Performs critical research and timely and accurate actions including preparing and submitting appropriate appeals or re-billing of claims to resolve coding denials to ensure collection of expected payment and mitigation of denials
• Maintains extensive caseload of coding denials.
• Formulates strategy for prioritizing cases and maintains aging within appropriate ranges with minimal direction or intervention from Leadership.
• Acts as a liaison among all department managers, staff, physicians and administration with respect to coding denials issues.
• Assists with the development of denial reports and other statistical reports.
• Reviews insurance coding-related denials, including but not limited to: Diagnosis codes not supported, incorrect or invalid CPT codes, modifier issues, and/or general coding error denials.
• Responsible for reviewing assigned diagnostic and procedural codes against patient charts using ICD-10-CM, CPT, or any other designated coding classification system in accordance with coding rules and regulations.
• Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures.
• Contacts insurance carriers as appropriate to resolve claim issues
• Maintains payer portal access and utilizes said portal to assist in reviewing commercial medical policies
• Maintains working knowledge of regulatory and third-party policies and requirements to ensure compliance; remains current with applicable insurance carriers’ timely filing deadlines, claims submission processes, and appeal processes and escalates timely filing requests to leadership.
• Assists with short-notice timely filing deadlines for accounts with coding issues.
• Provides feedback to the coding leadership team regarding coding denials.
• Compiles training material and educational sessions associated with coding denial-related topics and presents such educational materials. Collaboratively works with the coding education team & coding compliance team to assist in providing education to coders, physicians and mid-level providers.
• Monitors for coding trends, works collaboratively with the revenue cycle teams to prevent avoidable denials and reduce revenue loss.
• Identifies, quantifies and communicates risk concerns to leadership and supports mitigation efforts as appropriate. Demonstrates the ability to analyze coded data to identify areas of risk and provide suggestions for documentation improvement

Required

Experience 

• 5 years of coding-related experience such as coding, abstracting, Data Quality in coding function type as required by position. 
• 1 years experience in managing and appealing denials
• 1 years expertise in reading and interpreting commercial payer medical policies

License/Certification/Registration 

One of the following:

• Certified Coding Specialist-Professional (CCS-P)
• Certified Professional Coder (CPC)
• Registered Health Information Technician (RHIT)

Preferred 

Education 

• Bachelor’s Degree in HIM 

Experience 

• 7 years of coding related experience such as coding, abstracting, Data Quality in coding function type as required by position. 
• Epic experience 
• Hospital Billing 

License/Certification/Registration 

One of the following:

• Registered Health Information Administrator (RHIA)