Join Our Talent Network

Stay Connected with Catholic Health

Join Our Talent Network
Join our Talent Network

Diagnosis Related Group Validation & Denial Appeal Specialis

Location: Buffalo, NY, United States

Share: mail
Save Job Saved

Job Description

Facility: Administrative Regional Training Cntr

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: No

Work Schedule: Days

Hours:

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

VACCINE REQUIREMENTS

  • Effective January 1st 2022, you must be fully vaccinated with an FDA COVID-19 vaccination and provide proof of your vaccination status as part of your new employee pre-boarding. Exceptions to the COVID-19 vaccination requirement may be granted for medical reasons.
Share: mail

Similar Jobs

Talent Acquisition Advisor

Buffalo, NY, United States
Administrative Regional Training Cntr

Respiratory Therapy Apprentice

Buffalo, NY, United States
Sisters of Charity Hospital

Respiratory Therapy Apprentice

Buffalo, NY, United States
Sisters of Charity Hospital

Talent Acquisition Advisor

Buffalo, NY, United States
Administrative Regional Training Cntr

Social Worker MSW SCH

Buffalo, NY, United States
Sisters of Charity Hospital

Chemical Dependency Counselor Pathways SCH

Buffalo, NY, United States
Pathways Buffalo

Chemical Dependency Counselor Pathways SCH

Buffalo, NY, United States
Pathways Buffalo

Social Worker BSW Float N

Buffalo, NY, United States
Administrative Regional Training Cntr

Health Home Care Coordinator I

Buffalo, NY, United States
Administrative Regional Training Cntr

Talent Acquisition Advisor Clinical (RN) SCH

Buffalo, NY, United States
Sisters of Charity Hospital

Dietitian Nutritional Services SCH N

Buffalo, NY, United States
Sisters of Charity Hospital

Registered Nurse Care Manager Transition of Care SCH MSC SJC

Buffalo, NY, United States
Sisters of Charity Hospital

Clinical Specialist ICU MHB

Buffalo, NY, United States
Mercy Hospital of Buffalo

Health Home Care Coordinator I

Buffalo, NY, United States
Administrative Regional Training Cntr

Dietitian Nutritional Services MHB

Buffalo, NY, United States
Mercy Hospital of Buffalo

Patient Representative MHB

Buffalo, NY, United States
Mercy Hospital of Buffalo

Facility Planner

Buffalo, NY, United States
Administrative Regional Training Cntr

Clinical Advisor Talent Acquisition Niagara County

Buffalo, NY, United States
Administrative Regional Training Cntr

Coder Analyst Inpatient HIM MHB

Buffalo, NY, United States
Mercy Hospital of Buffalo

Clinical Transformation Team Administrator N

Buffalo, NY, United States
Administrative Regional Training Cntr

Facility Planner

Buffalo, NY, United States
Administrative Regional Training Cntr

Coder Analyst Health Information Home Care MSHC

Buffalo, NY, United States
Administrative Regional Training Cntr

Diagnosis Related Group Validation & Denial Appeal Specialis

Buffalo, NY, United States
Administrative Regional Training Cntr

Talent Acquisition Advisor

Buffalo, NY, United States
Administrative Regional Training Cntr