PB Coding Denials Integrity Specialist - Complex Specialties

Responsibilities

• Analyze and resolve coding-related PB denials using CPT, HCPCS, ICD-10-CM, and modifiers.
• Identify root causes, patterns, and trends in denial and rejection codes.
• Collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims.
• Conduct chart reviews to validate documentation against billed services.
• Prepare and support appeals by researching payer guidelines, coding standards, and coverage policies.
• Ensure accurate, compliant coding and sequencing aligned with official guidelines and payer requirements.
• Track, document, and report denial resolutions, appeal outcomes, and coding quality issues.
• Support compliance, quality assurance, and revenue integrity initiatives through issue monitoring and escalation resolution.
• Educate clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends.
• Contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.

Requirements

• Associate degree or equivalent education and experience required.
• Coding credential required (AHIMA or AAPC).
• 4 years of experience in expert-level professional coding or hospital-based coding.
• Experience in revenue cycle processes, health information workflows, and medical record auditing.
• Advanced knowledge of third-party reimbursement programs, state and federal regulatory issues, national and local coverage decisions, research-related restrictions, and ICD-10-PCS/CM, CPT, and HCPCS coding classification systems.
• Advanced knowledge of medical terminology, anatomy, and physiology.
• Advanced ability to identify coding discrepancies and provide recommendations for improvement.
• Advanced ability to analyze trends and data and display them in a statistical reporting format.
• Advanced knowledge of care delivery documentation systems and related medical record documents.
• Advanced knowledge of Medicare, Medicaid, and commercial payer coding guidelines.
• Advanced knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.
• Advanced interpersonal and communication (oral and written) skills, including the ability to effectively collaborate with multiple departments.
• Advanced organization and prioritization skills; ability to manage multiple priorities in a stressful, fast-paced work environment.
• Advanced analytical skills, with great attention to detail.
• Self-motivated with initiative and strong sense of ethics.
• Ability to work independently and exercise independent judgment and decision-making.
• Ability to meet deadlines while working in a fast-paced environment.
• Strong organizational skills and ability to work independently with limited guidance or direction.
• Effective critical thinking, creativity, problem-solving, and decision-making skills.

Physical Requirements and Working Conditions

• Position requires travel which will result in exposure to road and weather hazards.
• Operates the equipment necessary to perform the job.
• Exposed to a normal office environment.

Preferred Qualifications

• Second specialty credential preferred.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.