The Coding Denial Specialist performs advanced level work related to coding denial management. The individual is responsible for managing claim denials related to coding. The Coding Denial Specialist conducts comprehensive reviews of the claim denial, clinician notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a written appeal is needed, or if no action is needed.

The Coding Denial Specialist writes and submits professionally written appeals which include compelling arguments based on coding documentation, official coding references, and contract language. Appeals are submitted timely and tracked through final outcome. The incumbent will also handle audit-related / compliance responsibilities and other administrative duties as required.

This incumbent will actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle management. Additionally, the Coding Denial Specialist anticipates and responds to a wide variety of issues/concerns. The incumbent works independently to plan, schedule, and organize activities that directly impact hospital and physician reimbursement and assists in creating and maintaining documentation of key processes. This role is key to securing reimbursement and minimizing organizational write offs.

MAJOR RESPONSIBILITIES

Core Responsibilities:

• Research payer denials related to coding and billing resulting in denials and delays in payment.
• Independently write professional appeal letters.
• Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as UW Health policies and procedures.
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.
• Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
• Review payor communications, identifying risk for loss reimbursement related to coding policies and escalates potential issues to coding stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
• Identify opportunities for process improvement and actively participate in process improvement initiatives.

Customer Service Standards:

• Support co-workers and engage in positive interactions.
• Communicate professionally and timely with internal and external customers.
• Provide helpful assistance in anticipating and responding to the needs of our customers.
• Collaborate with customers in planning and decision making to result in optimal solutions.
• Ability to stay calm under pressure and deal effectively with difficult people