Description
Job Summary:
The Retrospective Appeal Coder provides support to the local coding departments by initiating the retrospective appeal process for coding denials. Drawing on a coding knowledge base and knowledge of payor regulations, the Retrospective Appeal Coder is responsible for assessing for the presence of criteria to recover denied reimbursement through appeal.
Responsibilities:
- Assist in determining system-wide coding needs through investigation of retrospective denials and identification of root cause. Review and resolve pre-bill edits as needed
- Maintain current knowledge of regulatory guidelines related to retrospective appeals.
- Serve as a liaison between coding and payors and facilitates payor/physician contact when indicated.
- Maintain collaborative relationships with coding management and appeal departments at payor organizations.
- Collaborate with other departments to ensure all information to support retrospective appeal is identified.
- Formulate written appeal letter as appropriate incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
- Perform coding review for cases referred for retrospective appeal/audits to determine if appeal is warranted.
- Act as liaison to other departments relative to the retrospective appeal process.
- Provide ongoing education to coding and other departments related to the appeal process.
- Ensure the appeal process is followed in order to accomplish timely and appropriate appeals.
- Identify and assign a root cause to each case to ensure denial reasons are tracked.
- Monitor and evaluate for areas of process improvement related to the retrospective appeal process.
Qualifications
- Bachelor's degree in Business Administration or related field or Registered Record Administrator (RAA) is preferred.
- Clinical Document Specialist/Clinical validation of coding experience is preferred
- 5 years Coding Experience required.
- Extensive knowledge of DRG/APC, ICD-9/10, CPT/HCPCS classifications and coding of diagnosis and procedures is required.
- Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required.
- Prior appeal/grievance experience preferred.
Licensure, Certifications, and Clearances:
- Certified Coding Specialist (CCS) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
- UPMC is an Equal Opportunity Employer/Disability/Veteran
Total Rewards
More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.
Our Values
At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.
