Medical Billing, Coding and Denial Specialist

Role Overview

• Assign accurate and compliant ICD-10-CM diagnosis codes for inpatient encounters
• Assign accurate and compliant ICD-10-PCS procedure codes
• Review physician documentation for completeness and accuracy
• Identify complications and comorbidities (CC/MCC) to ensure appropriate DRG assignment
• Query physicians for documentation clarification when necessary to support accurate coding
• Ensure compliance with all applicable coding guidelines including Official Guidelines for Coding and Reporting
• Assign accurate CPT/HCPCS codes for outpatient services
• Assign accurate ICD-10-CM diagnosis codes for outpatient encounters
• Perform APC assignment for outpatient services
• Code observation services in compliance with CMS guidelines
• Code emergency department encounters with appropriate E/M levels
• Code same-day surgery procedures
• Code outpatient diagnostic services (radiology, laboratory, cardiology, etc.)
• Review encounter/charge data for completeness prior to claim submission
• Prepare UB-04/837I institutional claims and CMS-1500/837P professional claims
• Validate all coding assignments and charges against documentation
• Validate critical data elements including: Member/patient identification numbers, National Provider Identifier (NPI) numbers, Provider taxonomy codes, Procedure modifiers, Units of service, Attending and operating provider information
• Verify compliance with payer-specific rules and requirements
• Perform claims formatting and compliance checks
• Submit claims electronically through designated clearinghouse or billing system
• Ensure timely electronic submission of claims within 48-72 hours of receiving complete information
• Monitor claim acceptance or rejection status
• Correct and resubmit rejected claims within 48 hours of notification
• Maintain compliance with payer filing limits and timely filing deadlines
• Manage clearinghouse transactions and resolve transmission issues
• Review and analyze claim denials and rejections
• Identify root causes of denials (coding errors, documentation deficiencies, registration issues, etc.)
• Correct coding or billing errors and resubmit claims
• Prepare appeals with supporting documentation when appropriate
• Track denial trends and recommend process improvements
• Work collaboratively with clinical documentation improvement (CDI) staff to address documentation issues
• Maintain 95% patient billing accuracy rate
• Ensure all coding and billing activities comply with: CMS regulations and guidelines, Medicare and Medicaid billing requirements, NCCI edits and bundling rules, Payer-specific policies and guidelines, HIPAA Privacy and Security Rules, HITECH Act requirements, GMHA privacy and security policies
• Participate in coding audits and quality assurance reviews
• Stay current with coding updates, regulatory changes, and payer policy modifications
• Complete continuing education requirements to maintain certifications
• Document all coding decisions, queries, and claim corrections
• Communicate effectively with physicians, clinical staff, and revenue cycle team members
• Provide coding education and guidance to clinical staff as needed
• Participate in team meetings and case reviews
• Maintain accurate records of work performed and productivity metrics

Requirements

• Minimum 10 years of hospital medical billing and coding experience
• 5+ years of demonstrated experience in supervisory role of hospital setting highly desirable
• Extensive experience with Emergency Room (ER) medical billing and coding
• Required system experience with one or more of the following: CareVue, VistA, CPRS
• Familiarity with hospital billing systems and clearinghouses
• Electronic claims submission experience
• Active certification as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) preferred
• Comprehensive knowledge of Medicare and Medicaid billing requirements
• Proficiency in ICD-10-CM diagnosis and procedure coding
• Proficiency in CPT/HCPCS coding
• Experience with UB-04/837I institutional claim formats & CMS-1500/837P professional claim formats
• Knowledge of APC (Ambulatory Payment Classification) assignment.

Benefits

• Comprehensive and competitive benefits package