Job Details

Job Description

ECU Health

About ECU Health

ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.

The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Childrens Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.

Position Summary

This role is responsible for analyzing coding denials by insurance carriers, CPT code(s), and specialty area, review and submission of coding appeals related to denials to include coding, bundling, duplicate, and other assigned denial volume. As well as responsible for the coordination and management of timely insurance claim follow-up including identifying, monitoring, appealing, and resolving denied claims and accounts. Perform detailed analysis on denied assigned claims with a focus on maximizing revenue and reimbursement. Utilizes provider documentation and queries, coding software tools and Insurance carrier medical and reimbursement policies during the claim review process.

Responsibilities

• Review and analyze coding, bundling, and duplicate denials including identification of root cause.
• Resolve coding denials which include researching and reviewing payer coding guidelines, writing and submitting appeals with supporting documentation.
• Analyzing assigned denials and making necessary corrections or modifications.
• Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
• Identify and provide coding denial trends by Payer, CPT code, or any other denial parameters.
• Performs searches of governmental, payor-specific, guidelines to identify and coding and billing requirements to make recommendations.
• Analyzes data from various sources (medical records, claims data, payer medical policies, etc.), determines the causes for denials of payment and partners with management to implement strategies to prevent future denials.
• Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical records submission.
• Performs timely review of medical records and remittances for denials in order to determine root cause and appropriateness.
• Partners with revenue cycle leadership, peers and clinical operations to reduce denials.
• Reviewing claim edits and denials and/or inquiries referred from other departments and assists in identifying root causes.
• Investigates the validity of the reasons for the denials and determines the need for or feasibility of submitting appeals.
• Attends coding conferences, workshops, and in house sessions to receive updated coding information and changes in coding and/or regulations.
• Develop process improvement initiatives from which problems can be resolved.
• Documents results of all special projects and provides recommendations for revenue managing opportunities.

Minimum Requirements

• Minimum of bachelor's degree or higher in a health service-related discipline. Five years of denial recovery experience or revenue cycle related field with a certificate in coding may be substituted.
• Previous auditing experience preferred. National Certification in an area relevant to Revenue Management or Coding is preferred.
• Proficiency in reimbursement methodologies, hospital information systems and coding methodologies.
• Illustrates creative problem-solving skills through documentation of process improvement reporting and/or internal reporting mechanisms.
• Ability to analyze complex medical records and identify billable services.
• Strong quantitative, analytical, and organizational skills.
• Understanding of medical records, professional/hospital claims, and the Charge master.
• Ability to utilize and understand computer technology.
• Ability to understand ancillary department functions.
• Possesses a comprehensive knowledge of various payment and coding methodologies, including ICD-10, HCPCS and CPT-4 coding schemes.
• Possesses a working knowledge of the UB-04/837 claim form loop and segments.
• Understands charging, coding processes along with compliance issues.
• Has the ability to provide resolutions by performing internet research, utilizing third party payor regulations, referencing coding guidelines, and referencing local Fiscal Intermediary and CMS guidelines.
• Requires knowledge of medical terminology, anatomy and physiology
• Must be team-oriented with strong interpersonal skills.
• Knowledge of the Privacy Act to safeguard patient confidentiality
• Coding Specialist or Procedural Coder certification

Other Information

• Remote position
• Monday - Friday day shift
• Great benefits

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General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicants qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.