Coding Denials Specialist

Primary Responsibilities

• Research payer denials related to coding, documentation, referral, pre‑authorization, notifications, medical necessity, non‑covered services, and billing resulting in denials and delays in payment.
• Conduct comprehensive reviews of the claim denial, account/guarantor notes, and the medical record to determine whether a revised claim, retro‑authorization, written appeal, or no action is required.
• Write and submit professionally crafted appeals that include compelling arguments based on clinical documentation, third‑party payer medical policies, and contract language; track appeals through outcome.
• Submit detailed, customized appeals to payers in accordance with Medicare, Medicaid, third‑party guidelines, and MCW/CPS compliance policies and procedures.
• Collaborate with the prior authorization team to obtain retro‑authorizations in response to authorization denials and expected denials.
• Identify denial patterns and escalate to management with sufficient information for follow‑up and root‑cause resolution.
• Recommend additions, revisions, or deletions to work queues and claim edits to improve efficiency and reduce denials.
• Review payer communications, identify reimbursement risk related to medical policies and prior‑authorization requirements, and escalate issues to clinical stakeholders, managed‑care contracting, and Revenue Cycle leadership.
• Identify opportunities for process improvement and actively participate in improvement initiatives.
• Other duties as assigned.

All remote work must be performed within one of the MCW registered payroll states: WI, AL, AZ, DE, FL, GA, IN, MD, MI, MN, MO, NC, TN, TX, & UT.

Knowledge, Skills, and Abilities

• Knowledge of payer policies and claims requirements.
• Advanced knowledge of CPT, ICD‑10 coding, and payer and governmental policies.
• Proficiency with EMR systems (EPIC) and Microsoft Office.
• Focus on continuous process improvement.
• Ability to adapt to frequent changes in duties and work volume.
• Effective communication and writing capabilities.
• Ability to manage multiple tasks with ease and efficiency.
• Strong interpersonal skills, teamwork promotion, and problem‑solving abilities.

Qualifications

• Minimum Required Education: High school diploma.
• Minimum Required Experience: Five (5) years in a health‑care setting, working in coding and/or reimbursement follow‑up.
• Required Certification/Licensure(s): Certified professional coder (CCS‑P, CPC, or CCA) and/or health information management credential (RHIT or RHIA).
• Preferred Education: Bachelor’s degree in business, health‑care management, or related fields.
• Preferred Experience: Five or more years of coding and/or reimbursement follow‑up experience in professional revenue‑cycle operations for large, multispecialty group practices or academic medical centers.

Benefits

• Outstanding health, vision, and dental coverage.
• Flexible Spending options.
• 403B retirement package.
• Competitive vacation and paid holidays.
• Tuition reimbursement.
• Paid parental leave.
• Employee & Family Assistance Program (EFAP).
• Pet insurance.
• On‑campus fitness facility with onsite classes.
• Discounted rates on select cell‑phone plans, local fitness facilities, Milwaukee recreation and entertainment, and more.