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Role Description
Responds to commercial payers, managed care and third party review organizations in managing the appeals/denials process. Supports the review of denial trends and identifies coding issues and knowledge gaps.
• Supports denial reviews and response processes; prioritizes and reviews cases denied by commercial payers.
• Reports program performance and/or corrective action to management on regular basis.
• Assists in monitoring inpatient denial types, volume and formulates responses to requesting agency; seeks additional resources (e.g. legal counsel) to resolve issues, as needed; develops case-specific written rationale to substantiate and communicate findings.
• Addresses coding issues and knowledge gaps; functions as an organization resource for litigation as related to coding denials.
• Maintains hospital database.
• Remains up-to-date on DRG system literature from all agencies.
• Maintains coding clinic updates.
• Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Qualifications
• Bachelor's Degree required, or equivalent combination of education and related experience.
• Current Professional Coder Certification, or Current Coding Professional Certification, or Current Registered Health Information Technician Certification required, plus specialized certifications as needed.
• 1-3 years of relevant experience, required.
• Knowledgeable on DRGs, preferred.
• Proficient in Microsoft Excel, preferred.
Company Description