Denials, Coding and Appeals Analyst

Denials, Coding and Appeals Analyst is responsible for identifying denial trends based on medical necessity, underpayments and presenting resolutions with the goal of denials reduction. The duties and responsibilities of a Denials and Appeals Coding Analyst is to evaluate the coding, as it affects the claims that are not reimbursed, via collaboration with the inpatient and outpatient coding departments and auditing. Focus on the quality of the claims submitted to ensure quality and compliance according to CMS guidelines. Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations. Receiving and reviewing patients' chart and documents for verification and accuracy. Review adverse determinations and claims to assist in the identification of denials and timely appeal referral with the goals of procuring reimbursement as well identifying denial root cause.

Requirements and Responsibilities:

A. Requirements:

1. Education Required - Evidence of continuing education courses, conferences or seminars. Bachelor's Degree preferred.
2. License/Certification/Registration(s) Required - Current New York State licenses if applicable.
3. Experience/Skills Required - 3-5 years clinical coding experience, preferably in an acute care hospital. Case Management/Denials and Appeals experience preferred. Managed Care experience is also preferred.
4. Demonstrate effective communication and problem solving skills.
5. Demonstrates strong organizational skills.

B. Requirements

• Following up and clarifying any information that is not clear to other staff members
• Collecting information made by the Physician from different sources to prepare monthly reports
• Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results
• Analyzing and identifying the medical procedures, diagnosis or events that lead to the claims denials.
• Monitoring the Claim Fail Billing (CFB) and generating reports for senior management as needed.
• Review payer correspondences including adverse determination letters, payer "End of Day Reports (EDOR)
• Utilize Case Management peer-to-peer log for most updated documented authorization status.
• Monitor trial balance for zero payment accounts missing authorization
• Assesses all denials by reviewing documentation of inpatient admission and continued stays, and technical adverse.
• Monitor payer website portals and payer provider manuals regarding changes to payer denials and appeals policies, and update SBH processes in accordance to changes that affect clinical review.
• Maintains communication with payers for follow up on authorization status and payments of retro record submissions.