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Overview
The Physician Coding Denials Specialist is responsible for reviewing and appealing coding denials for all assigned professional service claims related to Evaluation and Management coding. Closely works with Charge Coding & Revenue Management leaders and Account Resolution teams to provide feedback to providers/practices to improve clinical documentation and facilitate ongoing documentation improvement. Responsible for performing appeals for the Wellstar MGBO for professional services as deemed necessary. Monitor's denial work queues within Epic (Electronic Health Record) to ensure timely appeal deadlines are met. Must ensure timely, accurate and thorough appeals for all accounts assigned and apply critical thinking skills to ascertain root cause of denials. Uses analytical skills to identify trends in payer denials and translates this information into Charge Review edits that will be used to prevent future denials. Assists in development and implementation of training for charge capture specialists.

Responsibilities
Core Responsibilites and Essential Functions

Coding Denials Management
* Identify major reasons for denials root causes (Diagnosis, procedure codes, etc.)
* Work collaboratively with charge coding and revenue management to provide coding and documentation feedback to practices/providers.
* Utilize Epic to review account denial audits and perform trend analyses to identify patterns and variations in coding denials and practices.
* Maintain open communication with Wellstar Medical Group providers and practices to facilitate denial/appeals process.
* Review clinical records to identify overcharges, undercharges or charges that necessitate additional documentation.
* Research and analyze charge and coding requirements for new services and technology.
* Consistently meet current productivity and quality standards as assigned by department manager in ensuring accurate account follow-up.

Analysis and Interpretation of Trends
* Identify opportunities for system and process improvement and submit to management.
* Working with MGBO Edit Committee, physician coding compliance and Epic Connect, translate identified trends into Epic charge review rules.
* Evaluates and adheres to clinical and billing policies, guidelines, and regulations of both commercial and governmental payors.
* Appeals denials or instructs the resubmission of claims based on compliant medical record documentation and Wellstar Medical Group/MGBO policies and procedures.
* Asses need for formal appeals of all clinical denials including but not limited to preauthorization of practice encounters and procedures, and for retroactive recovery reviews regarding medical necessity and limited billing compliance.

Professional Communication
* Communicate with all internal contacts in a professional manner including providers, practice staff, co-workers, management, and clinical staff.
* Communicate with all external contacts in a professional manner including representatives from third party payor organizations.
* Interact with internal customers/departments including HIM, Charge Coding and Revenue Management, Patient Access and the Single Business Office in a professional manner to achieve revenue cycle department accounts receivable goals and objectives.
* Assure patient privacy and confidentiality as appropriate or required.
* Initiate communication with peers about changes in payor policies and internal policies and procedures.
* Prepare appeal letters that are specific, concise, and conclusive; providing payors with appropriate clinical documentation as needed.
* Provide feedback to physicians, providers and management in a timely and professional manner.

Department Methods, Procedures and Operations
* Follow department guidelines for lunch, breaks, requesting time off, and shift assignments.
* Demonstrate knowledge of the health system HIPAA privacy standards and ensure compliance with system PHI privacy practices.
* Follow the health system’s general Policy and Procedures, the Department’s Policy and Procedures, and the Emergency Preparedness Procedures.
* Follow JCAHO and outside regulatory agencies’ mandated rules and procedures.
* Participate in the testing for assigned software applications, including verification of field integrity.
* Perform other duties and responsibilities as assigned.

Required for All Jobs

Performs other duties as assigned

Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Qualifications
Required Minimum Education

High school diploma or equivalent Required

AAPC or AHIMA professional coding certification required Required or

>5 years of experience is acceptable with a professional certification within 90 days of employment Required or

If enrolled in a coding program within 90 days of graduation. Proof of enrollment required.

Required Minimum Experience

Minimum 2 years of Healthcare Account Resolution experience or Physician billing experience, including professional coding experience.
Required

Required Minimum Skills

High level problem solving, analytical and investigational skills to research and resolve denied accounts.

Technical skills to include Microsoft Office (Word, Excel, PowerPoint, Teams), EMR systems (Epic), graphs and tables experience and personal computers. Strong time management skills to independently manage multiple priorities and a heavy workload.

Demonstrated flexibility to perform other tasks as needed in an active work environment with changing work needs.

Ability to prioritize assignments to meet deadlines.

Proven communication skills and positive motivational skills.

Medical terminology and or anatomy/physiology, ICD-10, and E/M coding. Understand governmental and commercial payor compliance regulations.

Required Minimum License(s) and Certification(s)

Cert Prof Coder Preferred

Additional Licenses and Certifications

AAPC or AHIMA professional coding certification Required

CPB Preferred

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