Coding Denials Auditor

Key Responsibilities

• Conducts coding audits of submitted claims to determine appropriateness of procedure and diagnosis codes billed based on documentation provided for both outpatient facility and professional claims.
• Reviews Billing for accuracy to ensure compliance of proper billing and coding procedures of third-party carriers and to ensure complete and accurate reimbursement.
• Coordinates with revenue cycle teams to investigate rejected or denied claims to determine denial accuracy and work in an inter-departmental collaboration process to assist in claim corrections/appeals
• Effectively utilizes computer and appropriate software (Microsoft Office Suite) to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment, including a basic to intermediate level of competency in Excel which is required
• Maintains knowledge regarding medical coding and/or healthcare market changes.
• Gather and analyze claims and medical records information pertinent to documentation findings and outcomes; use this information to make educated decisions.
• Draft appeals to payors using nationally sourced coding guidelines such as CPT Assistant, specialty societies, state fee schedule language, AAPC/AHIMA articles etc.
• Other duties as required.

Requirements and Qualifications

• Associates or Bachelor’s Degree
• Current certification in one of the following: Certified Professional Coder (CPC) or related certification by AAPC, Certified Coding Associate (CCA) by AHIMA, Certified Coding Specialist (CCS) by AHIMA, Registered Health Information Technician (RHIT) by AHIMA.
• The applicant must have a strong background in orthopedics and surgery billing/coding. The ideal candidate has 5+ years of experience in orthopedic surgery billing, a solid background in coding and medical billing, with special emphasis on AR, EOB's, and overall account management, including coding denials.
• Must be able to gather and analyze claims and medical records information pertinent to documentation findings and outcomes; use this information to make educated decisions.
• Must have strong written communication skills. This position requires the ability to draft grammatically correct well written appeals to payors using nationally sourced coding guidelines such as CPT Assistant, specialty societies, state fee schedule language, AAPC/AHIMA articles etc.
• Sound time management skills with the ability to manage workload independently
• Strong analytical, problem solving and research skills with the ability to utilize creative thinking
• Must be comfortable with CAC/Encoder audits and be able to identify appropriate code selection from audit findings.
• Equivalent combination of education and experience will be considered.
• Ability and skill set to work remotely.
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions
• Must have strong computer proficiency and understand how to use basic office applications, including MS Office (Word, Excel, and Outlook).
• Regular and predictable attendance.

Special Considerations and Prerequisites

• Familiarity with healthcare documentation systems.
• Experience with multiple fee schedule concepts such as DRGs, APCs, and NCCI.
• Strong verbal, written and interpersonal communication and customer service skills.
• Ability to communicate audit outcomes and testing results with other staff within the company who are both medically and non-medically oriented.
• Ability to interpret policies and procedures and communicate complex topics to others.
• Ability to think critically and make decisions within individual role and responsibility.
• Complex Claims medical billing and coding experience strongly preferred.