Outpatient Coding Appeals Specialist

Key Responsibilities:

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers.
• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials, utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements.
• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission.
• Prepare and support coding‑based appeals by developing clear clinical and coding justifications
• Review medical records, payer policies, and coding guidelines to support appeal arguments
• Conduct in-depth coding audits and analysis to validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements.
• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance.
• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals.
• Compile and prepare detailed reports on coding-related denials, identifying patterns, trends, and opportunities for process improvement.
• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance.
• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies.
• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration.

Qualifications:

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification is required.
• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.
• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.
• Bachelor's degree: in Nursing, or any Medical or Health Information Management or a related field.
• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies.
• Excellent understanding of revenue cycle processes, claims processing workflows, and denials management.
• Proficiency in using coding software, encoders, and electronic health record (EHR) systems.
• Detail-oriented mindset with a high level of accuracy and organizational skills.
• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders.
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.
• Proficiency in using coding-related software and tools, as well as a high level of computer literacy.
• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring accurate and compliant coding practices that maximize reimbursement and support optimal healthcare delivery.