SUMMARY

The Clinical Coding Denial Specialist is responsible for reviewing and responding in a timely manner to DRG focused denials from external payers and their contractors. The Clinical Denial Specialist writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. This would include initial review of the denial focus area to determine whether an appeal is warranted. If supported, the Clinical Denial Specialist will ensure a timely response which addresses the specifics of the case and supports the coding based on documented clinical indicators. Collaborates closely with the DRG Denials Specialist and/or designated representative from a Physician Advisor to determine appropriate course of action for second and/or third level appeals. Appeals are submitted timely and tracked through final outcome. The Clinical DRG Denials Specialist will also handle audit-related / compliance responsibilities and other administrative duties as required.

Actively manages, maintains, and communicates denials and appeals activities to appropriate stakeholders and reports suspected or emerging trends related to payer denials to Coding and Clinical Documentation Improvement Leaders. Additionally, the Clinical Denial Specialist anticipates and responds to a wide variety of issues/concerns. Works independently to plan, schedule, and organize activities that directly impact hospital reimbursement and assists in creating and maintaining documentation of key processes. Prepares and submits cases for independent arbitration. Responsible for tracking all DRG denial related information across multiple platforms including denial tracking software, spreadsheets, and Care Connect. Assists with tracking and trending outcomes at each level and the overall success of the appeal process. Works collaboratively with DRG Denials Specialists, Coding, and Clinical Documentation Improvement leaders to provide feedback on targeted areas and results of denial activity in order to prevent future claim denials.
 

ATTRIBUTES

Bachelor’s degree or higher in a relevant field, including but not limited to: HIM, Nursing, or Billing/Finance required.Active RN licensure

RESPONSIBILITIES

Intakes, reviews, and responds to external payor audits for RRH facilities related to DRG assignment and clinical validation. Ensures timely responses are submitted with supporting documentation. Documents decisions throughout the appeal process and tracks cases to resolution. Works collaboratively with DRG Denials Specialist, Denial Coordinators, and HIM Operations to ensure the appeal and supporting documentation is submitted within contractual timeframes. Reviews and has knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations, National Coverage Determinations, Policy Bulletins, etc.Assists with continuous quality improvement of the established appeals process.Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors.Other related job tasks or responsibilities as assigned.
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EDUCATION:

AS: Health Information Management (Required)

LICENSES / CERTIFICATIONS: 

PHYSICAL REQUIREMENTS:

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$36.00 - $43.25

CITY:

Rochester

POSTAL CODE:

14617

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.
Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.