Overview 💰 Turn Denials Into Dollars and Drive Revenue Cycle Excellence. 💻 Work Style: Remote 📍 Location Requirement: Must reside in an approved state (FL, GA, PA, NC, SC, TN, or TX) 🕒 FTE: Full-Time (1.0 FTE) Responsible for maintaining low denial rates and optimizing reimbursement across the enterprise by ensuring high coding standards and effective denial management practices. Leads and supports initiatives to improve coding accuracy, reimbursement outcomes, and appeal turnaround times. Performs in-depth analysis of denial trends, including Epic system edits, coding validation, Charge Description Master (CDM) processes, authorization trends, and payer denials. Identifies opportunities for performance improvement and implements strategies to enhance revenue cycle outcomes. Educates departments on appropriate charging, billing, and coding practices to ensure regulatory compliance. Collaborates with Managed Care, Compliance, and operational teams to resolve complex issues with departments and payers, driving sustainable improvements in reimbursement and denial prevention.

Responsibilities

Key Responsibilities

• Manage and resolve clinical denials through claim corrections, resubmissions, authorization verification, payer reprocessing, reconsiderations, and appeals.
• Analyze denial trends and identify opportunities to improve coding accuracy, documentation quality, reimbursement outcomes, and denial prevention efforts.
• Research and resolve denials related to authorization, medical necessity, coding, billing, non-covered services, and payer policy requirements.
• Prepare and submit detailed appeals and reconsiderations supported by medical record documentation, coding guidelines, and payer requirements.
• Apply ICD-10-CM, CPT, HCPCS, NCCI, CMS, and payer-specific guidelines to review, validate, and correct coding and billing issues.
• Review and adjust charges, diagnosis coding, procedure coding, modifiers, and billing information to ensure regulatory compliance and reimbursement accuracy.
• Collaborate with Managed Care, Revenue Cycle, Compliance, Coding, and operational departments to resolve complex denial and reimbursement issues.
• Monitor payer communications, policy updates, reimbursement changes, and authorization requirements to identify risks and improve reimbursement performance.
• Track, trend, and report denial activity, root causes, and reimbursement opportunities while providing recommendations for process improvement.
• Participate in audits, compliance reviews, denial prevention initiatives, and revenue integrity activities to improve financial performance.
• Meet established productivity and quality standards while managing multiple payer work queues, including Medicare, Medicaid, government, and commercial payers.
• Educate departments on denial prevention strategies, coding accuracy, charge capture, documentation improvement, and reimbursement best practices.

Qualifications

Education

• High School Diploma or GED required.

Qualifications

• One (1) of the following coding certifications required: CPC, COC, RHIT, RHIA, or CCS.
• One (1) to two (2) years of coding experience required.
• One (1) to two (2) years of denial management and/or insurance-related experience required.