The Claim and Denial Coding Analyst role is a Certified Medical Coder who ensures clean claim submission and timely review and resolution of coding related claim denials for professional services, FQHC, MSO, and ASCs across the network. Utilizes provider documentation and queries, coding software tools and Insurance carrier medical and reimbursement policies during the claim review process.
JOB DUTIES AND RESPONSIBILITIES:
Maintain current knowledge of coding, compliance, and documentation guidelines
Resolve Charge Review and Claim Edit CCI/LCD edits, diagnosis coding errors and MUE frequency for clean claim submission
Resolve coding denials through claim correction or appeal. Claim corrections will be made after review of supporting documentation, CCI/LCD, carrier policy and utilization of coding software applications. The appeals process may include collaboration with the Claim Editing Manager, Physician, Specialty Coder, AR specialist or Auditor/Educator. Demonstrate the ability to formulate an appeal rationale based on clinical documentation, application of LCD, relative carrier policy and published Academy or Societal guidance
Provide coding guidance to providers and charge entry staff for single or low volume errors. Report high volume coding denial trends to the coordinator
Maintain meticulous documentation, spreadsheets, account, and claim examples of root cause issues. Performs searches of governmental, payor-specific, guidelines to identify and coding and billing requirements to make recommendations
Review TCM Charge Review encounters to verify the documentation supports all required TCM components. Relevel TCM service when not supported by the documentation or TCM has been rendered during another TCM 30-day period
Attends coding conferences, workshops, and in house sessions to receive updated coding information and changes in coding and/or regulations
Assists with training new staff in all aspects of the Analyst role.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting for up to 8 hours per day, 3 hours at a time. Standing and walking as necessary. Fingering and handling frequently, twisting and turning of hands occasionally. Pushing and pulling. Occasionally stoops, bends, squats, kneels and reach above shoulder level. Hearing as it relates to normal conversation. Seeing as it relates to general and near vision.
EDUCATION:
CPC or CCA certification required.
TRAINING AND EXPERIENCE:
At least 2 years of active E&M and/or Surgical Coding experience required. Must possess a comprehensive knowledge of ICD-10-CM, CPT and HCPCS coding. Knowledge and experience in dealing with third party insurance companies relative to claim processing and coding denials follow up. Epic Resolute experience helpful
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
St. Luke's University Health Network is a regional network of hospitals, physicians and other related organizations providing care primarily in Lehigh, Northampton, Monroe, Carbon, Schuylkill, Bucks, Montgomery and Berks counties in Pennsylvania and Warren County in New Jersey.
The Network provides services at more than 150 sites. St. Luke's University Health Network is comprised of six hospital sites. The Network includes:
Areas of exceptional medical expertise include:
St. Luke's offers an exceptional benefit plan for employees. Our values are reflected in all we do for patients, each other and the community:
Pride - We take pride in our accomplishments and in our organization.
Caring - We show consideration for others and their feelings. We treat others as we want to be treated.
Respect - We recognize the value, diversity and importance of each other, those we serve and the organization.
Accountability - We are responsible to make decisions and solve problems in a timely and effective manner.
Flexibility - We adapt to the changing needs and expectations of those we serve.
Teamwork - We work together to improve quality.
The mission of St. Luke's University Health Network is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.