Retrospective Appeals Coder

Life in Pittsburgh; Pittsburgh (Allegheny County); Remote; USD 85,000 - 120,000; Full time

Job summary

UPMC Corporate Revenue Cycle is seeking a Retrospective Appeal Coder to join our team in a remote capacity. The role supports local coding departments by initiating retrospective appeals for denials, utilizing a coding knowledge base and payor regulations to assess criteria for recovery.

Responsibilities include investigating retrospective denials, staying current with guidelines, liaising with payors, drafting appeal letters, reviewing codes for potential appeals, and educating teams on the

Qualifications

• Bachelor's degree in Business Administration or related field or RAA is preferred.
• Clinical Document Specialist/Clinical validation of coding experience is preferred
• 5 years Coding Experience required.
• Extensive knowledge of DRG/APC, ICD-9/10, CPT/HCPCS classifications and coding of diagnosis and procedures is required.
• Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.
• Prior appeal/grievance experience preferred.

Responsibilities

• Assist in determining system-wide coding needs through investigation of retrospective denials and identification of root cause. Review and resolve pre-bill edits as needed
• Maintain current knowledge of regulatory guidelines related to retrospective appeals.
• Serve as a liaison between coding and payors and facilitates payor/physician contact when indicated.
• Maintain collaborative relationships with coding management and appeal departments at payor organizations.
• Collaborate with other departments to ensure all information to support retrospective appeal is identified.
• Formulate written appeal letter as appropriate incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
• Perform coding review for cases referred for retrospective appeal/audits to determine if appeal is warranted.
• Act as liaison to other departments relative to the retrospective appeal process.
• Provide ongoing education to coding and other departments related to the appeal process.
• Ensure the appeal process is followed in order to accomplish timely and appropriate appeals.
• Identify and assign a root cause to each case to ensure denial reasons are tracked.
• Monitor and evaluate for areas of process improvement related to the retrospective appeal process.

Skills

Coding experience

DRG/APC knowledge

Medical terminology

Anatomy/Physiology

Pharmacology

Pathology

Appeals experience

Education

Bachelor's degree in Business Administration or related field

Registered Records Administrator (RAA)

Certified Coding Specialist (CCS)

Registered Health Information Administrator (RHIA)

Registered Health Information Technician (RHIT)

Act 34 compliance

Job description

UPMC Corporate Revenue Cycle is hiring a Retrospective Appeal Coder to join our team! This position will work remotely, Monday through Friday.

The Retrospective Appeal Coder provides support to the local coding departments by initiating the retrospective appeal process for coding denials. Drawing on a coding knowledge base and knowledge of payor regulations, the Retrospective Appeal Coder is responsible for assessing for the presence of criteria to recover denied reimbursement through appeal.

Responsibilities

• Assist in determining system-wide coding needs through investigation of retrospective denials and identification of root cause. Review and resolve pre-bill edits as needed
• Maintain current knowledge of regulatory guidelines related to retrospective appeals.
• Serve as a liaison between coding and payors and facilitates payor/physician contact when indicated.
• Maintain collaborative relationships with coding management and appeal departments at payor organizations.
• Collaborate with other departments to ensure all information to support retrospective appeal is identified.
• Formulate written appeal letter as appropriate incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
• Perform coding review for cases referred for retrospective appeal/audits to determine if appeal is warranted.
• Act as liaison to other departments relative to the retrospective appeal process.
• Provide ongoing education to coding and other departments related to the appeal process.
• Ensure the appeal process is followed in order to accomplish timely and appropriate appeals.
• Identify and assign a root cause to each case to ensure denial reasons are tracked.
• Monitor and evaluate for areas of process improvement related to the retrospective appeal process.

• Bachelor's degree in Business Administration or related field or Registered Record Administrator (RAA) is preferred.
• Clinical Document Specialist/Clinical validation of coding experience is preferred
• 5 years Coding Experience required.
• Extensive knowledge of DRG/APC, ICD-9/10, CPT/HCPCS classifications and coding of diagnosis and procedures is required.
• Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.
• Prior appeal/grievance experience preferred.

Licensure, Certifications, and Clearances

• Certified Coding Specialist (CCS) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran