Reviews and resolve accounts assigned via work list daily. Conducts account history research as required, including navigating patient electronic medical records (EMR) researching charge and payment histories, determining historic account and claim status changes, and reviewing documentation to determine appropriate course of appeal.
Collaborates with clinical staff and/or outside providers to obtain further information to be used in the appeals process.
Evaluates coding denials to determine root causes and creates processes for Denial Prevention and avoidance. Provide feedback on identified denial trends and root causes
Provides written appeals utilizing Official Coding Guidelines, Coding Clinic, CPT assistant and Coding Clinic as appropriate to defend the appeal.
Strong knowledge of DRG coding guidelines and provides written appeal letters for DRG disputes.
Assists with payer audits as required, tracking and trending the data that was pulled, opportunities and errors on the auditing bodies part, documenting and reporting as required to adjudicate these audits to full resolution.
Provides education regarding the proper use of CPT codes, modifiers, and diagnosis codes to comply with regulations set forth by the Center for Medicare & Medicare Services (CMS), managed care payers, PPO contracts, indemnity insurers, and all other healthcare payers.
Performs Peer coding audits on ED, OBS, and IP accounts as required.
Escalates any discrepancies and issues encountered to supervisors in a timely manner. Collaborates with appropriate AdventHealth departments and staff (e.g. patient access, clinical, patient financial services) when additional information or expertise is requested/required for accurate claim adjudication.
Participates in denials management committees and provides updates on coding related denials trends, issues and remediation plans as needed.
Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities.
Maintains a positive working relationship with internal staff and external providers, payer representatives and patients and acts in a professional, courteous manner at all times.
Performs other duties as assigned by management.
What You Will Need:
At least one year experience working payer denials for medical necessity, SSI and NCCI edits, incorrect procedure/diagnosis coding
At least five years recent acute care coding experience to include; Inpatient, ED, ancillary, observation, outpatient, and surgery coding.
Experience with HCPCS codes and resolution of OCE edits, SSI edits and CCI edits
Familiarity of the DRG reimbursement system
Medical Necessity and DRG appeal writing experience
Coding Audit experience
High school diploma or equivalent
RHIA, RHIT, CPC, or CCS certification or credential
Knowledge and Skills Required:
Thorough knowledge of medical terminology, anatomy & physiology and pathophysiology
Extensive understanding of Coding guidelines, CCI edits, CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, regulations and guidelines
Ability to read medical charts or dictation, understand services performed, and correlate those services to charges on the bill
Proficiency in Microsoft Suite applications specifically Excel, Word and Outlook
Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly
Technical proficiency within Patient Accounting system and applicable vendor technologies; position requires ability to navigate various modules within applicable technologies to perform account research
Self-starter with the ability to work under limited day-to-day oversight in a remote setting
Ability to educate others regarding coding guidelines
Ability to maintain required productivity and accuracy standards
The Denials Management Coding Specialist is responsible for investigating and resolving coding related denials from payers, preventing lost reimbursement and promoting denial prevention. The Denials Management Coding Specialist addresses both Inpatient and Outpatient claims and serves as a resource for all coding related questions and guidance to the Centralized Denial Team. The Denials Management Coding Specialist will adhere to the AdventHealth Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.