Associate Director, Denials and Appeals
Natera
CRC Coding Auditor
Tenet Healthcare
full-time
Posted on:
Origin: • 🇺🇸 United States • Colorado
Visit company websiteSalary
💰 $56,784 - $85,176 per year
Job Level
Mid-LevelSenior
About the role
- Conducts coding and documentation quality reviews and generates responses for cases denied by commercial and government payors to ensure claims coded and billed in accordance with coding guidelines, standards, regulations and payor guidelines.
- Performs analysis on clinical documentation, evidence based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials.
- Formulates and submits letters of appeal and creates effective appeals using clinical documentation supported by guidelines and evidence-based medicine.
- Performs reviews of accounts denied for DRG validation and DRG downgrades.
- Documents in appropriate denial tracking tool (ACE) and maintains/distributes reports to leadership.
- Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG’s, Outlier Payments, and Stop Loss calculations.
- Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
- Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.
Requirements
- Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment
- RN License in the State of Practice
- Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
- Three to Five years Clinical RN Experience
- Three to Five years of Clinical Documentation Integrity experience
- Must have expertise with Interqual and/or MCG Disease Management Ideologies
- Strong communication (verbal/written) and interpersonal skills
- Knowledge of CMS regulations
- Knowledge of inpatient coding guidelines
- 1-2 years of current experience with reimbursement methodologies
- RN,
- CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA
- Ability to lift 15-30lbs
- Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters, or other designated sites
- Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews
- Ability to work in a virtual setting under minimal supervision
- Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes
