Coding Appeals Specialist

sluhn; 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, claims data, and coding to ensure accurate MS-DRG assignments for appeals.

The role involves feedback to coding education, collaboration with medical staff, and drafting formal appeal letters to support network coding. Applicants should have at least 5 years of inpatient/outpatient coding experience, strong ICD-10-CM/PCS knowledge, and familiarity with EPIC and the 3M Encoder.

Qualifications

• Minimum 5 years inpatient/outpatient coding experience in acute care.
• Knowledge of ICD-10-CM/PCS, MS-DRG assignment and reimbursement rules.
• RHIA/RHIT and/or CCS certification preferred.

Responsibilities

• Conduct retrospective medical record reviews for code assignment and MS-DRG accuracy.
• Draft appeal letters to support network coding and defend coding decisions.
• Identify clinical documentation improvement issues and coordinate with physicians.
• Query physicians when codes or documentation are unclear or incomplete.
• Utilize EPIC and 3M Encoder to verify ICD-10-CM/PCS and MS-DRG assignments.

Skills

Coding accuracy

ICD-10 coding

MS-DRG assignment

EPIC

Medical record review

Physician communication

Education

RHIA

RHIT

CCS

Tools

3M Encoder

EPIC

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.