Clinical Appeals and CDI Specialist

Clinical Appeals and CDI Specialist

Full time & Part time/Remote

Coding AID, a division of Managed Resources Inc. is a nationwide leading provider of medical coding support, coding and compliance reviews, educational programs, recruitment, revenue cycle management, and many other managed healthcare solutions. We're proud to have served healthcare organizations and medical groups for 30 years with proven success in meeting their operational challenges.

Purpose

The Clinical Appeals and CDI Specialist uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation. This position works collaboratively with service lines to ensure that the clinical information within the client files/records are accurate, complete, and compliant.

The Clinical Appeals and CDI Specialist provides nurse consultation services that consist of reviewing and appealing for reconsideration of medical services that may have been denied, either in part or in whole, during the initial claims' determination phase. This position also provides education consultation services which include support of nurse education, client education, and consumer education through company webinars and seminars.

Job Description

• Review the cases, and determine the potential for a Provider Appeal, on the denied claim.
• Write quality appeal letters to achieve maximum overturn rate.
• Perform root cause data analysis on diagnoses, medical services, medical codes, and other indicators from reports and other tools.
• Review medical documents such as surgical reports, medical visits, and diagnostic reports in order to create educational strategies to ensure correct diagnosis code assignment by the client.
• Review clinical documentation and assign accurate diagnosis codes according to guidelines and project.
• Perform coding and appeals compliance audits.
• Be able to identify opportunities in diagnosis coding, clinical documentation, and billing within the client's day-to-day operations.
• Support on-going educational interventions to clients and staff to close gaps or related data.
• Support training in the form of white papers and webinars to clients, targeted groups and staff members.
• Performs initial reviews, concurrent reviews and retrospective reviews to ensure there is adequate supporting documentation.
• Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
• Identifies opportunities to improve client documentation and querying clients to ensure that appropriate documentation appears in the medical record.
• Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
• Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
• Develops and supports strong professional relationships with clients and staff members.
• Assists in special department projects or other needs as determined by service line department heads.
• Enhances department and organization reputation by accepting ownership for accomplishing new and different requests, exploring opportunities to add value to job accomplishments.
• Facilitates clarity of clinical information used for measuring and reporting which incorporates current DRG methodologies and/or other regulating/quality reporting bodies.
• Performs other duties relevant to the position.

Education and Experience

• Bachelor of Science in biology, nursing, business administration or related to the health industry from an accredited school.
• RN and Certified clinical documentation specialist credentials CDIP or CCDS (required).
• Certification in Case Management, Legal Nurse Consulting, or Coding a plus.
• Certificated coder (preferred) with at least 3+ years of experience in medical coding, medical billing, medical record reviewing, drug or provider representative experience. Recognized certifications by the American Academy of Professional Coders (AAPC) or American Health Information Management (AHIMA). These are: CRC, CPC, CIC, COC, CPC-P, CPMA, CDEO, CCS, CCS-P, CDIP, RHIA or RHIT.
• 3+ years' experience in clinical documentation improvement.
• Five years of acute hospital experience required.
• Working knowledge of billing codes, Revenue Codes, CPT's, etc.
• Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.
• Experience and success in appealing managed care denials and underpayment decisions.

CodingAID, a division of Managed Resources Inc., is an Equal Opportunity Employer (EOE) M/F/D/V/SO

Job Types: Full-time, Part-time

Pay: $ $45.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Application Question(s):

• Do you have 3+ years of recent experience and success in appealing managed care denials and underpayment decisions?

Experience:

• Medical coding: 3 years (Preferred)
• acute hospital: 5 years (Required)
• Clinical documentation improvement: 3 years (Required)

License/Certification:

• RN License (Required)
• CDIP (Required)
• CCDS (Required)
• CPC, CIC, COC, CPC-P, CPMA, CDEO, CCS, CCS-P, RHIA or RHIT. (Preferred)

Work Location: Remote