Diagnosis Related Group Validation & Denial Appeal Specialis
Job Description
Status: Full Time Facility: Administrative Regional Training Cntr
Work Schedule: Varied Shift: 1:
Exempt from Overtime: Exempt: No FTE: 1.000000: Bargaining Unit: ACE Associates
Summary:
This position is accountable for carrying out and documenting the appeals process for denied claims denied due to reasons including, but not limited to Diagnosis Related Group and Coding. The DRG Validation & Denial Appeal Specialist works with clinical and business associates to review and provide evidence based determination regarding the appealing, accepting and learnings from denials. The individual also works to maintain third-party payer relationships. This includes, but is not limited to, responding to inquiries, complaints, and other correspondence, and may include setting up arbitration between parties. Knowledge of state and federal laws relating to contracts and appeal processes is vital. Works closely with the CDEI educators to address discrepancies as well as develop tools and processes to improve performance as needed. Uses specialized tracking software to preform chart reviews and track trends to report to coding and financial leadership. Assists in the development of Catholic Health System's coding and clinical documentation guidelines. The position acts as a liaison between front-end areas and third party payers in scenarios related to denials and appeals.
Responsibilities:
EDUCATION
- A minimum of an associates in a healthcare-related, information system or business field required
- Certification in at least one of the following is required:
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
- Certified Coding Associate (CCA)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Professional Coder-Hospital (CPC-H)
- Certified Documentation Improvement Practitioner (CDIP)
EXPERIENCE
- Three (3) to Five (5) years of medical coding experience in an acute healthcare setting required
- Must have experience coding both ICD-9 and ICD-10
- One (1) - two (2) years of auditing experience preferred
KNOWLEDGE, SKILL AND ABILITY
- Holds extensive knowledge of the following:
- DRG methodologies and protocols
- Hospital and professional coding systems, including ICD-9, ICD-10, CPT and HCPCS
- Clinical documentation procedures and regulations
- Coding Clinics, Guidelines as well as Federal and state regulations as they relate to code assignment
- Managed care, government, and third-party payer reimbursement requirements
- Has experience issuing or appealing DRG Reassignment denials
- Excellent interpersonal skills working with the medical, nursing, case management, patient accounts, finance, managed care services and third party payors
- Strong verbal and written communication and presentation skills
- Demonstrates organizational skill, problem solving skills, facilitation, critical thinking and decision making
- Extensive knowledge of regulatory guidelines for ICD-9CM, ICD-10CM, CPT-4 and DRG Methodologies
- Knowledge of Managed Care Organization contracts/agreements
- PC literate, spreadsheet work, analytical skills for reporting and interpretation
WORKING CONDITIONS
- Occasional travel between CH facilities required
ENVIRONMENT
- General office environment
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