Coding Denials Specialist - Clinical Practice Services

Medical College of Wisconsin; Wisconsin; On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Health insurance

403B retirement package

Competitive vacation & holidays

Tuition reimbursement

EFAP (Employee & Family Assistance)

Job summary

Medical College of Wisconsin is seeking a Coding Denials Specialist to manage advanced level denials related to coding edits and claim denials. The role involves researching payer denials, preparing timely appeals, and collaborating with prior authorization to minimize adjustments.

The ideal candidate has deep CPT/ICD-10 knowledge, experience with EPIC, and strong written communication skills, with at least five years in healthcare coding or reimbursement follow-up.

Qualifications

• Minimum education: High school diploma.
• Minimum 5 years in a healthcare setting working in coding or reimbursement follow up.
• Certification: CCS-P, CPC, or CCA or RHIT/RHIA licensure.
• Preferred: Bachelor’s degree in business, healthcare management, or related field.

Responsibilities

• Research payer denials related to coding and documentation.
• Review denials, determine if revised claim, retro authorization or written appeal is needed.
• Write and submit professional appeals with supporting policy and contract language.
• Submit detailed appeals to payers following Medicare, Medicaid and third-party guidelines.
• Collaborate with prior authorization to obtain retro-authorizations.
• Identify denial patterns and escalate for root-cause resolution.
• Suggest improvements to work queues and claim edits to reduce denials.
• Review payer communications and flag potential issues for stakeholders.
• Identify opportunities for process improvement and participate in initiatives.
• Perform other duties as assigned.

Skills

Payer policies

CPT/ICD-10 coding

EMR knowledge (EPIC)

Microsoft Office

Written communication

Multitasking

Teamwork

Education

High school diploma

Bachelor’s degree in business/healthcare

Tools

EPIC EMR

Microsoft Office

Job description

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 escalates 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 policies.
• Proficiency with EMR’s (EPIC) and Microsoft Office. Focus on continuous process improvement. Ability to react to frequent changes in duties and volume of work.
• Effective communication skills and writing capabilities / efficiencies.
• Ability to manage multiple tasks with ease and efficiency.
• Effective interpersonal skills, including the ability to promote teamwork, strong problem-solving skills.

Qualifications

Minimum Required Education: High school diploma

Minimum Required Experience: Five (5) years of experience in a health care setting, working in coding and/or reimbursement follow up.

Required Certification/Licensure(s): Certified professional coder (CCS-P, CPC, or CCA) and/or health information management credential (RHIT or RHIA).

Preferred Education: Bachelor’s degree in business, health care management, or related fields.

Preferred Experience: Five+ (5+) years of coding and/or reimbursement follow up experience in professional revenue cycle operations for large, multispecialty group practices and/or academic medical centers.

Why MCW?

• Outstanding Healthcare Coverage, including but not limited to Health, Vision, and Dental. Along with Flexible Spending options
• 403B Retirement Package
• Competitive Vacation and Paid Holidays offered
• Tuition Reimbursement
• Employee & Family Assistance Program (EFAP)
• Pet Insurance
• On campus Fitness Facility, offering onsite classes
• Additional discounted rates on items such as: Select cell phone plans, local fitness facilities, Milwaukee recreation and entertainment etc.

For a brief overview of our benefits see: Benefits Overview

For a full list of positions see: MCW Careers