DRG & Coding Appeals Specialist

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 75,000 - 98,000; Full time

Job summary

St. Luke's University Health Network is seeking a Coding Appeals Specialist to analyze patient records, claims data and coding to assure proper MS-DRG assignments for audits and payer reviews.

The role focuses on retrospective chart reviews, documenting issues, drafting appeal letters, and collaborating with physicians and coding staff to improve documentation and reimbursement outcomes.

Qualifications

• 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.

Responsibilities

• Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
• Identify and provide feedback to the Network Coding and CDMP Managers for education of the medical staff and coding professionals on documentation issues that affect proper documentation and coding 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 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 communicate with physicians, nurses, coding and other members of the health care team 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.

Education

RHIA, RHIT and/or CCS

Job description

St. Luke's University Health Network is seeking a Coding Appeals Specialist to analyze patient records, claims data and coding to assure proper MS-DRG assignments for audits and payer reviews.

The role focuses on retrospective chart reviews, documenting issues, drafting appeal letters, and collaborating with physicians and coding staff to improve documentation and reimbursement outcomes.