Coding Appeals Specialist

St. Luke's University Health Network - Allentown, PA

Part-time - Mid Level

Allentown, PA

Hospitals

About the position

The Coding Appeals Specialist plays a crucial role in ensuring the accuracy of medical coding and diagnosis assignments for patient records. This position involves reviewing medical records and claims data to support appeals against coding changes proposed by insurance providers. The specialist prepares detailed appeal arguments and letters, ensuring compliance with coding guidelines and regulations, while maintaining high standards of accuracy and productivity.

Responsibilities

• Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy for inpatient encounters and CPT assignment for OP encounters.
• Analyze DRG or CPT denial letters and draft appeal letters, including supporting clinical documentation from record, supporting clinical evidence, and the coding argument, to support network coding.
• Develop and maintain appeal log, files, PAMS in Epic and workflow documents demonstrating activity and results, documents related to close outs including but not limited to CDE1 notes, coding education log, including monthly report preparation and distribution to the coding leadership team.
• Oversee account changes pertaining to accepted and/or appealed audit recommendations and work with staff assisting with clerical and administrative tasks related to the appeals/audit function.
• Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement.
• Facilitate clinical reviews to assist with supporting assigned diagnosis and/or procedures of medical conditions as documented in the patient medical record.
• Maintain productivity as outlined in current Performance Improvement Plan.
• Maintain 95% accuracy of coding and DRG denial decision to appeal rate as measured through quality reviews.
• Stay current on ICD-10-CM/PCS coding and MS-DRG principles, UHDDS, CMS guidelines and AHA coding guidelines; CPT procedural coding; 3M Encoder; use of EPIC HIM Coding profile.
• Work with the physician advisor in review of patient medical records identified by RAC/MIC/QIO and other insurers or outside auditors in retrospective reviews for DRG and coding-related issues.
• Identify clinical documentation improvement issues and work independently to resolve such issues.
• Query physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment or appeal writing.
• Participate as needed in Administrative Law Judge (ALJ) hearings.
• Demonstrate excellence in standards of professionalism, in compliance with Network and department policies, regarding electronic communication, virtual meetings, internet interaction with colleagues, and working remotely.
• Demonstrate financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

Requirements

• RHIA, RHIT and/or CCS certification with expert knowledge of 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.
• Demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting.
• Knowledge of anatomy and physiology, pathophysiology, and medical terminology required.
• Extensive knowledge of reimbursement systems and federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and medical necessity.

Nice-to-haves

• Previous experience with auditing preferred.
• Working knowledge of electronic patient medical record/EPIC and 3M encoding system preferred.

Benefits

• Flexible work schedule upon request and prior agreement with manager.