Coding Appeals Specialist

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 70,000 - 90,000; Full time

Job summary

St. Luke's University Health Network seeks a Coding Appeals Specialist to analyze patient records, review diagnosis and procedure codes, and ensure proper MS-DRG assignment for appeal purposes. The role involves education of clinical teams and collaboration with payors to secure accurate reimbursement.

Qualified candidates will have RHIA/RHIT/CCS credentials, 5+ years inpatient coding experience, and strong knowledge of ICD-10-CM/PCS, plus experience with EPIC and 3M Encoder.

Qualifications

• RHIA, RHIT and/or CCS certification with knowledge of ICD-9-CM/ICD-10-CM/PCS and MS-DRG assignment.
• Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting.

Responsibilities

• Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
• Identify trends and provide feedback to educate medical staff and coding professionals on documentation and coding issues affecting reimbursement.
• Collaborate with physician liaison and review records identified by RAC/MIC/CGI/QIO for DRG and coding-related issues.
• Develop and apply appeal arguments to defend coding decisions and refute payor determinations.
• Query physicians when documentation is unclear to ensure accurate coding and coding consistency.

Skills

Medical terminology

Anatomy & physiology

Attention to detail

Education

RHIA/RHIT/CCS certification

Tools

EPIC

3M Encoder

Job description

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors. Assures that the most accurate and descriptive codes from the AHA ICD-9-CM/ICD-10-CM/PCS diagnoses and/or procedures support the services/treatment rendered.

JOB DUTIES AND RESPONSIBILITIES

• Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
• Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement.
• Work with the physician liaison in review of patient medical records identified by RAC/MIC/CGI/QIO and other outside auditors in retrospective reviews for DRG and coding-related issues.
• May participate in review of other medical necessity issues as needed.
• Develop and apply appeal arguments to defend the coding of and by the coding professionals and be able to refute the coding determination made by the outside payor including but not limited to CMS, Aetna, IBC, Omniclaim, QIP, Gateway Health, etc.
• Draft appeal letters, including the coding argument, to support network coding.
• Identify clinical documentation improvement issues and through excellent communication with physicians, nurses, coding and other members of the health care team and work independently to resolve such issues.
• Participate as needed in Administrative Law Judge (ALJ) hearings.
• Spends approximately 20% of their time weekly coding/abstracting patient medical records according to ICD-10-CM/PCS, UHDDS and CMS guidelines.
• Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes, and MS-DRG assignment.
• Performs data entry of coded patient medical records into EPIC, maintaining a 95% coding accuracy rate as measured through quality reviews.
• Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment.

PHYSICAL/SENSORY DEMANDS

Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation.

EDUCATION

RHIA, RHIT and/or CCS with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment. Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required.

TRAINING, KNOWLEDGE AND EXPERIENCE

Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting. Knowledge of anatomy and physiology, pathophysiology, and medical terminology required. Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred. Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity. Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.

St. Luke's University Health Network is an Equal Opportunity Employer.

Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row.

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