Coding Denials Managemet Specialist (HIM Inpatient), Senior - HIM Financial - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

In accordance with current federal & state coding compliance regulations and guidelines, the HIM Coding Denials Management Specialist" analyze, investigate, mitigate, and resolve all coding-related 'claims denials' and 'claims rejections,' specific to ICD-10-CM, ICD-10-PCS, CPT/HCPCS, DRGs, APCs, and Modifiers—from Medicare, Medi-Cal, MAC, RAC, and commercial insurance companies —when there is refusal or rejection to honor Keck Medicine of USC request for payment for both IP & OP healthcare services provided to covered patients. Manages the denial management process for coding-related denials, triage denied claims to distinguish coding-related denials versus clinical-related denials, evaluating claims deemed inappropriately paid by the payer/external auditors, and determining the need for appeal. Performs all 1st and 2nd level coding-related denial appeals. All tasks & duties to be perform in compliance with federal & state coding laws, rules, regulations, Official Coding Guidelines, AHA Coding Clinic, AMA CPT Assistance, NCCI, NCD, LCDs, etc. Analyze, investigate, and resolve coding-related pre-bill edits from the Patient Financial Services (PFS) Dept. Researches, responds, and documents findings, correspondence, and notes regarding coding-related 'claims denials' and 'claims rejections' on patient accounts in both the Coding & Billing systems. Responsible for reviewing reports/work queues to identify and to correct the root cause for claim rejections and denials which might prevent or delay payment of a particular claim or group of claims. Prepares appeals and rebuttals letters/packages in responses to payer's reason for coding-related 'claims denials' and 'claims rejections'—including documentation and an argument and follow up with the PFS about possible reimbursement. Identifies, analyzes, and researches frequent root causes of denials and develops corrective action plans for resolution of denials. Develop reporting tools that effectively measure and monitor processes throughout the denials management process in order to support process improvement. Initiates appropriate CDI query engagements with Coders & CDI Specialists in order to acquire or clarify the necessary clinical documentation needed to facilitate accurate and complete coding, abstracting, and DRG assignments. Participate in responses to inquiries regarding coding and clinical documentation from Coders, CDI Specialists, and all other internal & external customers. Performs other HIM Coding Department duties as assigned by the HIM leadership team. Excellent written and oral communication skills are required, as well as effective human relations and leadership skills for building and maintaining a working relationship with all levels of staff, physicians, and other contacts. Must possess the ability to: interact professionally and ethically with third parties including stakeholders, co-workers, and management; handle multiple tasks simultaneously. Provide clear, concise oral and written directives/communications; quickly assess situations and respond appropriately; handle special requests in a sensitive, professional manner. Demonstrates the ability to perform in-depth clinical & regulatory research Re: NCD, LCD, NCCI, Official Coding Guidelines, AHA Coding Clinic, CPT Assistant, etc. Ability to problem solve, prioritize and organize, follow directives with accuracy and precision. In addition, this position will provide guidance and training to other HIM Coding Denials Management Specialist, and will assist with escalated issues.

Essential Duties:

• CODING AUDITING • Performs monthly internal coding audits to evaluate accuracy of coding staff to ensure a 95% coding accuracy rate. • Develops monitoring/education plans for coding staff who do not meet the 95% accuracy rate. • Recognizes education needs of staff based on monthly reviews and conducts related in-services, as needed. • Ability to act as a resource to coding and hospital staff on coding issues and questions. • Ability to achieve a 95% accuracy rate as determined by an annual external review of coding.
• ABSTRACTING AUDITING • Performs monthly internal abstracting audits to evaluate accuracy of coding staff to ensure a 95% abstracting accuracy rate. • Develops monitoring/education plans for coding staff who do not meet the 95% accuracy rate. • Recognizes education needs of staff based on monthly reviews and conducts related in-services, as needed. • Ability to act as a resource to coding staff on difficult coding issues.
• UNDER GENERAL SUPERVISION, RESPONSIBLE FOR • Provide guidance and training to other HIM Coding Denials Management Specialists. • Performs all 1st and 2nd level coding-related denial appeals. • Inpatient coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstractin