Denial Coding Specialist
Job Summary
The Denial Coding Specialist is a key member of the Revenue Cycle team, responsible for overseeing the review and appeal of coding-related denials. This role focuses on analyzing coding guidelines, driving claims recovery, and identifying root causes of denials. The specialist partners cross-functionally to support a thorough denial management process and resolve underlying revenue cycle issues contributing to denials.
Key Responsibilities
Denial Review & Appeal Management: Make preliminary determinations on whether coding denials can be recovered and assess the need for further appeal submissions.
Research & Documentation: Research and prepare appeal files in response to coding denials, ensuring all necessary documentation and support are included.
Root Cause Analysis: Analyze coding denials to identify underlying issues and work towards resolving them effectively.
Resolution of Denials: Resolve coding and benefit exhausted denials by researching payer guidelines, preparing appeals, and submitting them as necessary.
Escalation of Errors: Identify coding, billing, or reimbursement errors within denied or aging claims and escalate to the CHS Director of Denials for further action.
Reimbursement Evaluation: Assess denied dollars in comparison to expected reimbursements, identifying discrepancies and discrepancies in payments.
Medical Necessity Review: Review denials requiring coding or medical necessity evaluations and prepare appeal responses.
Tracking & Trend Analysis: Track and trend denial issues, escalating leadership to assist with process improvements.
Special Projects: Participate in special projects as assigned to improve denial management processes.
Who You Are & What You’ll Bring
Minimum of 5 years of medical coding experience.
Strong knowledge of the managed care landscape, including payer structures and government programs.
Solid understanding of the National Correct Coding Initiative (NCCI) guidelines.
Deep expertise in insurance reimbursement, billing practices, and payment compliance regulations, including denials and appeals recovery.
Familiarity with a variety of reimbursement methodologies, including PerDiem, DRG, fee schedules, percentage of charges, and stop loss.
Proficiency in coding and classification systems impacting claims adjudication, such as ICD9, CPT, HCPCS, DRG, APG, APC, and revenue codes.
Strong problemsolving skills with the ability to anticipate challenges and proactively implement solutions.
Excellent collaboration skills, with the ability to work both independently and as part of a team.
Proven ability to identify process gaps and drive operational improvements.
Exceptional analytical, investigative, and attentionto-detail capabilities.
Strong verbal and written communication skills.
Ability to effectively prioritize and manage workload to ensure timely, accurate results.
Adaptability in a fastpaced environment with evolving processes and requirements.
Working knowledge of industrystandard criteria (e.g., InterQual, Milliman Care Guidelines, NCCN).
Ability to build strong crossfunctional relationships and contribute to overall team success.
Motivation to support continued growth and evolution of denial management processes.
Education/Certifications
Bachelor’s degree preferred; equivalent work experience of at least 7 years will also be considered.
Certification: CPC Certified Professional Coder or COCCertified Outpatient Coder and CICCertified Inpatient Coder.
Physical Requirements
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, and pulling objects. Sitting most of the time, walking and standing required only occasionally.