Coding Denials Specialist - Clinical Practice Services

Medical College of Wisconsin; Wauwatosa (WI); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health insurance

403B retirement plan

Paid time off & holidays

Tuition reimbursement

Parental leave

Employee & Family Assistance Program

Pet Insurance

On-campus fitness facility

Discounted rates for services

Job summary

Medical College of Wisconsin is seeking a Coding Denials Specialist to manage complex coding denials, appeals and related correspondence. You will analyze denials, collaborate with prior authorization, and drive process improvements in a dynamic Revenue Cycle team.

The role requires extensive coding knowledge (CPT/ICD-10), payer policies, and strong communication skills. A CCS, CPC, or CCA and/or RHIT/RHIA are preferred; a bachelor’s degree is a plus.

Qualifications

• Minimum required education: High school diploma.
• Minimum five years of experience in a health care setting, working in coding and/or reimbursement follow up.
• Certified professional coder (CCS-P, CPC, or CCA) and/or health information management credential (RHIT or RHIA).
• Preferred: Bachelor's degree in business, health care management, or related fields.
• Preferred experience: five+ years in coding/reimbursement follow up in large multispecialty or academic centers.

Responsibilities

• Research payer denials related to coding, documentation, and billing resulting in denials and delays in payment.
• Review denial details and associated notes to decide actions on revised claims or retro authorizations.
• Write and submit appeals with compelling arguments based on documentation, policies, and contracts.
• Submit detailed, customized appeals per Medicare/Medicaid and payer guidelines as well as MCW policies.
• Collaborate with prior authorization to obtain retro-authorizations per payor requirements.
• Identify denial patterns and escalate with information for root-cause resolution.
• Suggest improvements to queues/claim edits to reduce denials.
• Review payer communications and flag risk for loss reimbursement to stakeholders.
• Participate in process improvement initiatives.
• Other duties as assigned.

Skills

Payer policies

CPT ICD-10 coding

EPIC EMR

Microsoft Office

Communication skills

Multi-tasking

Teamwork & problem-solving

Education

High school diploma

Bachelor's degree in business/healthcare management or related fields

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.

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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

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.