Overview:
Work remotely while using your denial management expertise to make a direct impact on healthcare operations.
Work Style: Remote
Location Requirement: Must reside in an approved state (FL, GA, PA, NC, SC, TN, or TX)
FTE: Full-Time (1.0 FTE)
Responsible for maintaining low denial rates and optimizing reimbursement across the enterprise by ensuring high coding standards and effective denial management practices. Leads and supports initiatives to improve coding accuracy, reimbursement outcomes, and appeal turnaround times.
Performs in-depth analysis of denial trends, including Epic system edits, coding validation, Charge Description Master (CDM) processes, authorization trends, and payer denials. Identifies opportunities for performance improvement and implements strategies to enhance revenue cycle outcomes.
Educates departments on appropriate charging, billing, and coding practices to ensure regulatory compliance. Collaborates with Managed Care, Compliance, and operational teams to resolve complex issues with departments and payers, driving sustainable improvements in reimbursement and denial prevention.
Responsibilities:
Key Responsibilities:
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Manages clinical denials from clinical denial workqueues including claim resubmission, authorization verification, payer claim reprocessing, claim reconsiderations, and appeals.
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Works closely with managed care teams and payers to reduce denials and increase reimbursement.
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Develops recommendations for coding and documentation process improvements based on denial analysis and coding guidelines.
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Completes assigned work within established productivity and accuracy standards, including processing assigned denial workqueues while maintaining quality expectations.
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Uses coding software, NCCI, ICD-10, CPT, HCPCS, and CMS coding guidelines to accurately review, code, and correct accounts.
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Collaborates with department managers to report, track, and resolve denials. Assists with investigations and audits to identify, correct, trend, and report charging, coding, and billing compliance issues.
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Manages assigned payer workqueues including Medicare, Medicaid, government payers, commercial payers, Medicare Advantage plans, and other payer types.
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Researches payer denials related to authorization, medical necessity, non-covered services, coding, and billing, and initiates timely reconsiderations and appeals to prevent filing denials.
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Prepares detailed, customized reconsiderations and appeals based on medical record review and organizational policies and procedures.
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Identifies denial trends and escalates root cause findings to management for additional follow-up and process improvement.
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Reviews payer communications to identify reimbursement risks related to medical policies, coverage requirements, and prior authorizations.
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Reviews and corrects coding, modifiers, diagnosis sequencing, and charges in accordance with coding, charging, and billing guidelines.
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Partners with departments to educate staff and improve documentation, coding, charging, and authorization processes to reduce denials and improve reimbursement.
Qualifications:
Minimum Qualifications:
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High School Diploma or GED required
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One of the following coding certifications required: CPC, COC, RHIT, RHIA, or CCS
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1–2 years of coding experience, along with 1–2 years of denial management and/or insurance-related experience
