Senior Coding Denials Management Specialist; HIM Inpatient - HIM Financial

In accordance with current federal & state coding compliance regulations and guidelines, the HIM Coding Denials Management Specialist analyzes, investigates, mitigates, and resolves 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, triages denied claims to distinguish coding‑related denials versus clinical‑related denials, evaluates claims deemed inappropriately paid by the payer/external auditors, and determines the need for appeal. Performs all 1st and 2nd level coding‑related denial appeals in compliance with federal & state coding laws, rules, regulations, Official Coding Guidelines, AHA Coding Clinic, AMA CPT Assistance, NCCI, NCD, LCDs, etc.

Analyzes, investigates, and resolves 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 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 rebuttal 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. Develops reporting tools that effectively measure and monitor processes throughout the denials management process to support process improvement.

Initiates appropriate CDI query engagements with Coders & CDI Specialists to acquire or clarify the necessary clinical documentation needed to facilitate accurate and complete coding, abstracting, and DRG assignments. Participates 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. Provides 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. Provides guidance and training to other HIM Coding Denials Management Specialists, and will assist with escalated issues.

• Perform monthly internal coding audits to evaluate accuracy of coding staff and ensure a 95% coding accuracy rate.
• Develop monitoring and education plans for coding staff who do not meet the 95% accuracy rate.
• Conduct related in‑services and serve as a resource to coding and hospital staff on coding issues and questions.
• Perform all 1st and 2nd level coding‑related denial appeals and provide guidance and training to other HIM Coding Denials Management Specialists.
• Inpatient coding of all diagnostic and procedural information using ICD‑10‑CM, ICD‑10‑PCS, CPT/HCPCS, and Modifier classification systems, and abstract patient information as established and required by…