Inpatient Clinical Appeal Specialist at Yale New Haven Health in New Haven, Connecticut

Job Description:

OVERVIEW To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The OP Clinical Denial Appeal Specialist supports the organization by...???.. and participating in the process of developing, submitting, tracking, and trending Outpatient Clinical Denials and identifying opportunities to prevent the reoccurrence. This individual works closely with colleagues within the organization and with managed care payers to resolve coding related policy or contract issues, expediate reimbursement on overturned appeals, and to prevent further unnecessary financial loss.

EEO/AA/Disability/Veteran

RESPONSIBILITIES

* 1. Evaluates DRG denials against documentation in the medical record to determine the viability of appeals, clinical indicators and develop and submit appeal correspondence and ensures timely follow up on DRG appeals.

* 2. Collaborate with Coding and CDI Educator to provide educational opportunities derived from common themes discovered through the appeal process in an effort to prevent future denials.

* 3. Track key denial data as they relate to departmental metrics and performance. Develop and maintain key metrics report including the identification of trends, action plans, etc. Attend organizational committees to present data as required.

* 4. Collaborate with Physician Advisors and the CDI Educator to resolve documentation discrepancies and clinical disparities, escalation of clinical and coding issues and physician education.

* 5. Communicate directly with payer and coordinate meetings with contracting and payers as needed to support appeals process.

* 6. Coordinate Peer to Peer appeal reviews as needed.

* 7. Perform other duties as assigned.

QUALIFICATIONS

EDUCATION

Two (2) years of college or equivalent with additional training in medical terminology and anatomy. Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) is required; RHIT, RHIA preferred. Knowledge of coding, billing, and the revenue cycle. Working knowledge of human anatomy and physiology , diseases and processes, demonstrated knowledge of medical terminology and organization of the medical record coding systems. Certified Revenue Cycle Specialist (CRCS) preferred.

EXPERIENCE

Five (5) years of coding and billing related claim edits experience required (coding outpatient medical records, ICD-9, ICD-10, CPT-4, and Evaluation & Management classification systems). Previous experience with both governmental and managed care denial and appeal process as well as governmental RAC audits. Epic HB billing knowledge preferred.

LICENSURE

Certified Coding Specialist (CCS), Certified Coding Specialist - Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) is required; RHIT, RHIA preferred. Certified Revenue Cycle Specialist (CRCS) preferred

SPECIAL SKILLS

In-depth knowledge of medical terminology, anatomy, physiology, and disease process. Comprehensive understanding of ICD-10-CM classification systems. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures. Ability to analyze and resolve technical and medical necessity payer denials through in depth knowledge of payor policies and appeal procedures. Previous experience with clinical denials and appeals for all payers preferred.