Denial Coding Auditor
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.Job Responsibilities/Duties
The Denial Coding Auditor coordinates and oversees the DRG downgrade team and is an expert on DRG downgrade appeals and denials management. This individual will represent the hospital where claims were denied by either governmental contractors or commercial payers. The individual will complete comprehensive reviews of clinical documentation and existing coding to determine if an appeal is warranted and provide coding guideline reference material to support the appeal. The individual will also handle audit-related correspondence and other administrative duties as required. He or she will also troubleshoots and resolves issues as they arise and functions as a role model and resource to staff.
- Coordinates the daily operations of the department, troubleshooting and resolving issues as they occur. Educates others on coding/appeals/denials guidelines on an ongoing basis. Performs as a role model and consistently demonstrates an advanced level of expertise and enhanced communication skills.
- Reads, understands and abstracts information from patient medical records in electronic and scanned paper formats within an EMR, meeting all department productivity goals, for identified payor populations as directed.
- Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required.
- Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence from existing library of clinical references.
- Performs duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, and all regulatory agencies, including State and Federal. Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
- Researches medical literature and evidence based medical publications to support the level of care provided.
- Reviews/audits patient claims with medical necessity denials looking for patterns by services or by the ordering physician. Follow-up in improving clinical documentation to reduce such denials. Works collaboratively with health information management coding staff, physicians and financial services to resolve payment denials and documentation issues.
Minimum Education: Medical Graduate, Physician Assistant or Registered Nurse (Current CA License).Employee Value Proposition
Minimum Experience: Three (3) years previous coding/appeals/denials experience.
Req. Certification/Licensure: CCS or CPC certification.
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:
How to Apply
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
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We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
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Certified Professional Coder