The Christ Hospital Cardiovascular Associates
Denials Specialist - CBO Medical Records Services - Full Time - Days
The Christ Hospital Cardiovascular Associates, Norwood, Ohio, United States
Job Description
The Denial Specialist performs advanced level work related to post payment government denials and is responsible for reviewing and resolving claim denials related to ICD-10 CM, ICD-10 PCS, CPT, or HCPCS coding discrepancies, ensuring compliance with healthcare regulations, payer guidelines, while collaborating and assisting internal stakeholders to support code accuracy on post- billed accounts and post payment audits, securing appropriate reimbursement for hospital and physician services.
The Denials Specialist reviews denied claims and post payment government audit and writes and submits professionally written appeals which include compelling arguments based on clinical documentation, correct coding in third-party payer medical policies, and contract language.
The specialist ensures timely and accurate responses to payer denials, actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle Leadership and contributes to process improvement strategies that reduce future denials. This role is key to securing reimbursement and minimizing organizational write offs.
Responsibilities
Research and analyze claim denials related to level of care, authorizations, medical necessity, and non-covered services. Write and submit professional appeal letters based on documentation, coding guidelines, and denial reason. Identify denial patterns and escalate 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, claim edits, to improve efficiency and reduce denials. Conduct comprehensive reviews of medical records to ensure documentation supports the services billed. Collaborate with healthcare providers to address gaps in documentation and coding. Ensure compliance with Medicare, Medicaid, and third-party payer guidelines. Identify patterns in denials and recommend process improvements to reduce future occurrences. Monitor payer communications and escalate potential issues to management. Participate in initiatives to enhance efficiency and compliance in denial management. Work closely with clinical and administrative teams to resolve denial-related issues. Prepare reports on denial trends and present findings to leadership. Communicate effectively with payers to resolve disputes and secure reimbursement. Adhere to compliance regulations, the Christ Hospital Code of Conduct, and the Christ Hospital Core Values and AHIMA code of ethic while performing all duties detailed.
Qualifications
KNOWLEDGE AND SKILLS:
EDUCATION:
High school diploma or equivalent required; Associate's degree in a business or healthcare related field preferred. Two (2) years of relevant experience and required credentials outlined below may be considered in lieu of an Associate's degree.
YEARS OF EXPERIENCE:
Two years of coding experience preferred.
REQUIRED SKILLS AND KNOWLEDGE:
Demonstrated in depth knowledge of ICD-10 and CPT coding guidelines, medical terminology, anatomy, and physiology. Ability to accurately code diagnosis, diagnostic and surgical procedures in multiple specialties with in-depth of knowledge in Evaluation and Management (E/M) coding. Strong knowledge of legal, regulatory, and policy compliance issues related to medical coding and documentation. Level of care knowledge required. Demonstrated effective verbal and written communication skills, including with physicians and groups. Research skills including knowledge of automated analysis tools and on-line research tools to resolve complex coding and healthcare issues. Demonstrated ability to effectively work within a team environment, using excellent written, verbal, and presentation skills to share audit findings, risk areas, and compliance issues with coders, office managers, physicians, etc. Maintains confidentiality and always protects sensitive data. Excel Proficiency: Strong Excel skills including data management and data interpretation. Focus on continuous process improvement.
LICENSES REGISTRATIONS &/or CERTIFICATIONS:
RHIT, CCS, CPC, CCA required. RHIA, CRC, CPMA, preferred.
The Denial Specialist performs advanced level work related to post payment government denials and is responsible for reviewing and resolving claim denials related to ICD-10 CM, ICD-10 PCS, CPT, or HCPCS coding discrepancies, ensuring compliance with healthcare regulations, payer guidelines, while collaborating and assisting internal stakeholders to support code accuracy on post- billed accounts and post payment audits, securing appropriate reimbursement for hospital and physician services.
The Denials Specialist reviews denied claims and post payment government audit and writes and submits professionally written appeals which include compelling arguments based on clinical documentation, correct coding in third-party payer medical policies, and contract language.
The specialist ensures timely and accurate responses to payer denials, actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle Leadership and contributes to process improvement strategies that reduce future denials. This role is key to securing reimbursement and minimizing organizational write offs.
Responsibilities
Research and analyze claim denials related to level of care, authorizations, medical necessity, and non-covered services. Write and submit professional appeal letters based on documentation, coding guidelines, and denial reason. Identify denial patterns and escalate 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, claim edits, to improve efficiency and reduce denials. Conduct comprehensive reviews of medical records to ensure documentation supports the services billed. Collaborate with healthcare providers to address gaps in documentation and coding. Ensure compliance with Medicare, Medicaid, and third-party payer guidelines. Identify patterns in denials and recommend process improvements to reduce future occurrences. Monitor payer communications and escalate potential issues to management. Participate in initiatives to enhance efficiency and compliance in denial management. Work closely with clinical and administrative teams to resolve denial-related issues. Prepare reports on denial trends and present findings to leadership. Communicate effectively with payers to resolve disputes and secure reimbursement. Adhere to compliance regulations, the Christ Hospital Code of Conduct, and the Christ Hospital Core Values and AHIMA code of ethic while performing all duties detailed.
Qualifications
KNOWLEDGE AND SKILLS:
EDUCATION:
High school diploma or equivalent required; Associate's degree in a business or healthcare related field preferred. Two (2) years of relevant experience and required credentials outlined below may be considered in lieu of an Associate's degree.
YEARS OF EXPERIENCE:
Two years of coding experience preferred.
REQUIRED SKILLS AND KNOWLEDGE:
Demonstrated in depth knowledge of ICD-10 and CPT coding guidelines, medical terminology, anatomy, and physiology. Ability to accurately code diagnosis, diagnostic and surgical procedures in multiple specialties with in-depth of knowledge in Evaluation and Management (E/M) coding. Strong knowledge of legal, regulatory, and policy compliance issues related to medical coding and documentation. Level of care knowledge required. Demonstrated effective verbal and written communication skills, including with physicians and groups. Research skills including knowledge of automated analysis tools and on-line research tools to resolve complex coding and healthcare issues. Demonstrated ability to effectively work within a team environment, using excellent written, verbal, and presentation skills to share audit findings, risk areas, and compliance issues with coders, office managers, physicians, etc. Maintains confidentiality and always protects sensitive data. Excel Proficiency: Strong Excel skills including data management and data interpretation. Focus on continuous process improvement.
LICENSES REGISTRATIONS &/or CERTIFICATIONS:
RHIT, CCS, CPC, CCA required. RHIA, CRC, CPMA, preferred.