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...

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