In accordance with current federal & state coding compliance regulations and guidelines, the HIM Coding Denials Management Specialist" analyze, investigate, and resolve all coding-related 'claims denials' and 'claims rejections,' specific to ICD-10-CM, ICD-10-PCS, CPT/HCPCS, and Modifiers—from Medicare, Medi-Cal, MAC, RAC, and commercial insurance companies or carrier—when there is refusal to honor provider's request for payment for both IP & OP healthcare services provided to covered patients. Manages the denial management process for coding related denials, triage denials claims to distinguish coding-related denials versus clinical-related denials, evaluating claims deemed inappropriately paid by the external payer/auditor and determining the need for appeal. All tasks & duties to be perform in compliance with federal & state coding laws, rules, regulations, Official Coding Guidelines, AHA Coding Clinic, AMA CPT Assistance, NCCI, NCD, LCDs, etc. Analyze, investigate, and resolve 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 to 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 rebuttals 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. Develop reporting tools that effectively measure and monitor processes throughout the denials management process in order to support process improvement. Initiates appropriate CDI query engagements with Coders & CDI Specialists in order to acquire or clarify the necessary clinical documentation needed to facilitate accurate and complete coding, abstracting, and DRG assignments. Participate 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. Provide 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.

Essential Duties:

• CODING AUDITING
• Performs monthly internal coding audits to evaluate accuracy of coding staff to ensure a 95% coding accuracy rate.
• Develops monitoring/education plans for coding staff who do not meet the 95% accuracy rate.
• Recognizes education needs of staff based on monthly reviews and conducts related in-services, as needed.
• Ability to act as a resource to coding and hospital staff on coding issues and questions.
• Ability to achieve a 95% accuracy rate as determined by an annual external review of coding.
• ABSTRACTING AUDITING
• Performs monthly internal abstracting audits to evaluate accuracy of coding staff to ensure a 95% abstracting accuracy rate.
• Develops monitoring/education plans for coding staff who do not meet the 95% accuracy rate.
• Recognizes education needs of staff based on monthly reviews and conducts related in-services, as needed.
• Ability to act as a resource to coding staff on difficult coding issues.
• UNDER GENERAL SUPERVISION, RESPONSIBLE FOR
• Inpatient coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions.
• Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity.
• Enter patient information into inpatient and outpatient medical record databases (ClinTrac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission.
• Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes.
• Assists in the correction of regulatory reports, such as OSHPD, as requested.
• Attendance, punctuality, and professionalism in all HIM Coding and work related activities.
• Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion.
• Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee.
• CODING & ABSTRACTING ACCURACY
• Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s).
• Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s).
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting.
• Recognizes education needs of based on monthly reviews and conducts self-improvement activities.
• Ability to act as a resource to coding and hospital staff on coding issues and questions.
• CODING OPTIMIZATION
• Ability to improve MS-DRG assignments related to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APR-DRG, SOI, and ROM assignments related to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APC/HCC assignments based on medical necessity documentation & coding of PDx, SecDx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• TIMELINESS OF AUDITING/CODING & PRODUCTIVITY
• Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort.
• Works coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service.
• Works coding queues/task lists to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service.
• Assist other coders in performance of duties including answering questions and providing guidance, as necessary.
• Assists Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues/questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding issues/questions, as needed.
• Assists in the monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority.
• CONTINUING EDUCATION
• Maintains AHIMA and or AAPC coding credential(s) specified in the job description.
• Attend coding & CDI seminars, webinars, and in-services to maintain the required annual continued education units (CEU).
• Keep up-to-date and reviews ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant to maintain knowledge of the principles of coding.
• Keep up-to-date and reviews other professional journals and newsletters in a timely fashion to maintain knowledge of the principles of coding.
• Consistently attend and actively participate in the daily huddles.
• POLICY & PROCEDURES; PERFORMANCE IMPROVEMENT
• Consistently adhere to HIM policies and procedures as directed by HIM management.
• Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed.
• Participates in continuously assessing and improving departmental performance.
• Ability to communicate changes to improve processes to the director, as needed.
• Assists in department and section quality improvement activities and processes (i.e. Performance Improvement).
• COMMUNICATION
• Works and communicates in a positive manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel.
• Ability to communicate effectively intra-departmentally and inter-departmentally.
• Ability to communicate effectively with external customers.
• Provides timely follow-up with both written and verbal requests for information, including voice mail and email.
• Performs other duties as assigned.
• SYSTEMS
• Working knowledge and efficient navigation of the Electronic Health Record (EHR): Cerner/Powerchart & Coding mPage.
• Working knowledge, efficient navigation, & full use of 3M-CRS Encoder system; utilize to expedite coding process; utilize all references.
• Knowledge & understanding of PFS system (PBAR) functionality and any interface with the coding abstracting system: ClinTrac.
• Working knowledge, efficient navigation, & full use of ‘HDM/HRM/ARMS Core’ coding & abstracting software.
• Working knowledge, efficient navigation, & full use of ‘3M 360 Encompass/CAC’.

Required Qualifications:

• High school or equivalent
• Specialized/technical training Successful completion of college courses in Medical Terminology, Anatomy & Physiology and a certified coding course. Must possess a thorough knowledge of ICD/DRG coding and/or CPT/HCPCS coding principles, and the recommended American Health Information Management Association (AHIMA) coding competencies.

• 10 years Experience in ICD, CPT/HCPCS coding of inpatient & outpatient medical records in an acute care facility.
• Experience in using a computerized coding & abstracting database software and encoding/code-finder systems [e.g., 3M 360 Encompass/CAC & 3M Coding & Reimbursement System (CRS)].

• Working knowledge of CPT, HCPCs and ICD9 coding principles
• Organization/time management skills.
• Demonstrate excellent customer service behavior.
• Demonstrates excellent verbal and written communication skills.
• Able to function independently and as a member of a team.

Preferred Qualifications:

Required Licenses/Certifications:

• AHIMA Certified Coding Specialist (CCS) only; or AAPC Certified Inpatient Coder (CIC) only; or either the CCS or CIC in conjunction with any one of the following national HIM credentials: 1. AHIMA Registered Health Information Technician (RHIT) 2. AHIMA Registered Health Information Administrator (RHIA) Successful completion of the hospital specific coding test – with a passing score of ≥90%. The coding test may be waived for former USC or agency/contract HIM Coding Dept. coders who historically/previously met the ≥ 90% internal/external audit standards of the previously held USC Job Code.

Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)