Coding Denials Specialist - Clinical Practice Services

The Medical College of Wisconsin, Inc.; Madison (WI); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Vision and dental coverage

401(k) plan

Job summary

The Coding Denials Specialist at The Medical College of Wisconsin, Inc. will handle advanced denials management, reviewing claims and supporting documentation to determine if revised submissions or appeals are required.

The role emphasizes accurate coding, documentation review, and timely payer communications to minimize denials. Applicants should bring strong CPT/ICD-10 knowledge, proficiency with EPIC and Office tools, and the ability to analyze trends for process improvements within a

Qualifications

• 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.

Responsibilities

• Research payer denials related to coding, documentation, and billing.
• Review denials and supporting documents to determine necessary actions (re-submission, retro-authorization, appeals).
• Write and submit professional appeals with supporting policy language.
• Collaborate with prior authorization to obtain retro-auths as needed.
• Identify denial patterns and recommend process improvements.
• Escalate issues with appropriate stakeholders as needed.
• Perform other duties as assigned.

Skills

Payer policies

CPT coding

ICD-10 coding

EPIC EMR

Microsoft Office

Communication

Writing skills

Education

High school diploma

CCS-P or CPC or CCA

RHIT or RHIA

Bachelor’s in related field (preferred)

Tools

EPIC

Microsoft Office

Job description

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 elevate 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. #LI-RT1

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 Paid Parental Leave 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

Values

At MCW all of our endeavors, from our internal operations to our interactions with our partners, are driven by our shared organizational values: Caring - Collaborative - Curiosity - Inclusive - Integrity - Respect. We are committed to fostering an inclusive environment that values diversity in backgrounds, experiences, and perspectives through merit-based processes and in alignment with all applicable laws. We believe that embracing human differences is critical to realize our vision of a healthier world, and we recognize that a healthy and thriving community starts from within. Our values define who we are, what we stand for and how we conduct ourselves at MCW. If you believe in embracing individuality and working together according to these principles to improve health for all, then MCW is the place for you. For more information, please visit our institutional website.

MCW as an Equal Opportunity Employer and Commitment to Non-Discrimination

The Medical College of Wisconsin (MCW) is an Equal Opportunity Employer. We are committed to fostering an inclusive community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the MCW community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic.

About Us

Together, we can build a healthier world. A student, an educator, a scientist and a community leader - alone, they can do many things. Together, the question isn’t what they can do, but what can’t they. The Medical College of Wisconsin (MCW) brings together the most inquisitive, passionate minds in science, medicine, education and community engagement to tackle today’s toughest challenges in health and society. Academic medicine is at the center of where scientists, physicians and students work hand-in-hand with the community to ask the most important questions and fuel the cycle of innovation that shapes the future of medicine. Medical College of Wisconsin The tireless pursuit of knowledge and the power of academic medicine is at the core of everything we do at MCW. Bringing together the world’s top scientists and clinicians, inspired students and invested communities, we are driven to solve the most..