Medical College of Wisconsin

Position Description:

The Coding Denials Specialist performs advanced level work related to coding denials management. The individual is responsible for resolving coding claim edits, coding-related claim denials & coding correspondence, monitoring for trends and assist in the analysis, development, and implementation of solutions to minimize avoidable denials and adjustments.

This role is 100% remote for the following states: WI, FL, MN, NC, TN, & TX.

Responsibilities:

• Research payer denials related to coding, documentation, referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
• Conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is needed.
• Writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through outcome.
• Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as MCW/CPS and compliance policies and procedures.
• Collaborate with the prior authorization team to obtain retro-authorizations in accordance with payor requirements in response to authorization denials and expected denials.
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.
• Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
• Identify opportunities for process improvement and actively participate in process improvement initiatives.

Knowledge – Skills – Abilities

Knowledge of payer policies and claims requirements. Advanced knowledge of CPT, ICD-10 coding, payer and governmental policies. Proficiency with EMR’s (EPIC) and Microsoft Office. Focus on continuous process improvement. Ability to react to frequent changes in duties and volume of work. Effective communication skills and writing capabilities / efficiencies. Ability to manage multiple tasks with ease and efficiency. Effective interpersonal skills, including the ability to promote teamwork, strong problem-solving skills.

Preferred Schedule:

Full-time role with expectations for coverage during core business hours and flexibility required as necessary to accommodate business needs.

Position Requirements:

Minimum Qualifications:

Appropriate experience may be substituted for education on an equivalent basis

Minimum Required Education: High school diploma

Minimum Required Experience: Five (5) years of experience in a health care setting, working in coding and/or reimbursement follow up.

Certification: Certified professional coder (CCS-P, CPC, CCA) and/or health information management credential (RHIT or RHIA).

Preferred Qualifications:

Preferred Education: Bachelor’s degree in business, health care management, or related fields.

Preferred Experience: Five or more (5+) years of coding and/or reimbursement follow up experience in professional revenue cycle operations for large, multispecialty group practices and/or academic medical centers.

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Why MCW?

• Outstanding Healthcare Coverage, including but not limited to Health, Vision, and Dental. Along with Flexible Spending options
• 403B Retirement Package
• Competitive Vacation and Paid Holidays offered
• Tuition Reimbursement
• Paid Parental Leave
• Pet Insurance
• On campus Fitness Facility, offering onsite classes.
• Additional discounted rates on items such as: Select cell phone plans, local fitness facilities, Milwaukee recreation and entertainment etc.

For a full list of positions see: www.mcw.edu/careers

For a brief overview of our benefits see: https://www.mcw.edu/departments/human-resources/benefits

MCW as an Equal Opportunity Employer and Commitment to Non-Discrimination

The Medical College of Wisconsin (MCW) is an Equal Opportunity Employer. We are committed to fostering a diverse community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the MCW community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic.

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