Coding Appeals Specialist

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset Individually and together, our employees are dedicated to satisfying the mission of our organization which 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.

The Coding Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their respective auditors. Ensures the most accurate and descriptive diagnoses and procedure codes from the ICD-10-CM/PCS official code set, or AMA CPT, are assigned to support the services/treatment rendered. The Coding Appeals Specialist also prepares appeal arguments and/or letters to support and defend the codes reported.

JOB DUTIES AND RESPONSIBILITIES:

ESSENTIAL FUNCTIONS:

1. Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy for inpatient encounters and CPT assignment for OP encounters.

2. Analyze DRG or CPT denial letters and draft appeal letters, including supporting clinical documentation from record, supporting clinical evidence, and the coding argument, to support network coding.  Develop and apply appeal arguments to defend the coding assigned by the coding professionals and be able to refute the coding determination made by any government, commercial, or outside payor or their vendor representative.

3. Develops and maintains appeal log, files, PAMS in Epic and workflow documents demonstrating activity and results, documents related to close outs including but not limited to CDE1 notes, coding education log, including monthly report preparation and distribution to the coding leadership team.

4. Oversees account changes pertaining to accepted and/or appealed audit recommendations and works with staff assisting with clerical and administrative tasks related the appeals/audit function.

5. Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement.

6. In collaboration with the appropriate clinical staff, including but not limited to Physician Advisor, Chief of Services, CDMP leadership team, etc., facilitates clinical reviews to assist with supporting assigned diagnosis and/or procedures of medical conditions as documented in the patient medical record.

7. Maintains productivity as outlined in current Performance Improvement Plan.

8. Maintains 95% accuracy of coding and DRG denial decision to appeal rate as measured through quality reviews.

9. Responsible for maintaining up-to-date knowledge of ICD-10-CM/PCS coding and MS-DRG principles, UHDDS, CMS guidelines and AHA coding guidelines; CPT procedural coding; 3M Encoder; use of EPIC HIM Coding profile.

10. Responsible to remain current on clinical criteria as it pertains to AHA, Official Coding Guidelines for Coding and Reporting of Diagnoses and Procedures, and Nuance CDI program strategies for clinical documentation or current program in use for clinical documentation management program.

11. Work with the physician advisor in review of patient medical records identified by RAC/MIC/QIO and other insurers or outside auditors in retrospective reviews for DRG and coding-related issues. 

12. Identify clinical documentation improvement issues, and through excellent communication with physicians, clinical documentation specialists, coding and other members of the health care team, and work independently to resolve such issues.

13. Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment or appeal writing.

14. Participate as needed in Administrative Law Judge (ALJ) hearings.

15. Demonstrates/models the hospital's PCRAFT core values, Network’s Service Excellence Standards of Performance, and customer service behaviors in interactions with all customers, internal and external.

16. Maintain confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.

17. Comply with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.

18. Demonstrates excellence in standards of professionalism, in compliance with Network and department policies, regarding electronic communication, virtual meetings, internet interaction with colleagues, and working remotely.

19. Demonstrate Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.

20. Demonstrate financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

21. Comply with Network and departmental policies regarding attendance and dress code.

OTHER FUNCTIONS:

Participates in meetings as designated. Assists in training of new personnel Other related duties as assigned.

PHYSICIAL AND SENSORY REQUIREMENTS

PHYSICAL/SENSORY DEMANDS:  Sitting, standing and light lifting.   Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range.  Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation.

POTENTIAL ON-THE-JOB RISKS:  No identified risks.

SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE:  N/A

MOST COMPLEX DUTY:  Ability to apply objective understanding of ICD-10-CM/PCS coding conventions and CPT guidelines.   Appropriately assign diagnosis and procedure codes for accurate reimbursement. 

COMMUNICATIONS:  Communicate frequently in a tactful, respectful, and diplomatic manner with internal and external customers to include, but not limited to, physicians, hospital employees and vendors.  Advises Network CDI & DRG Denials Manager on issues requiring immediate attention.

ADDITIONAL REQUIREMENTS:  Expected to maintain designated CEUs for AHIMA credentials (RHIA, RHIT, and/or CCS) in accordance with the AHIMA Governing Body, with confirmation of valid credentials for every two-year cycle reporting.  Adherence to the confidentiality guidelines as outlined within the Hospital and departmental policies.  Promote positive customer satisfaction by way of prompt and courteous customer service.

QUALIFICATIONS

(MINIMUM)

EDUCATION:

RHIA, RHIT and/or CCS with expert knowledge ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment.  Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required.  Previous experience with auditing preferred.

TRAINING, KNOWLEDGE AND EXPERIENCE:

Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting.  Knowledge of anatomy and physiology, pathophysiology, and medical terminology required.  Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred.  Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity.  Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.

WORK SCHEDULE:

Day shift but may require other hours as necessary. Per diem position is flexible upon request and with prior agreement with manager.

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 an Equal Opportunity Employer.

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