Outpatient Coding Appeals Specialist

We are  seeking  for   a detail-oriented and analytical Clinical Coding Analyst to join our team and take on the responsibility of reviewing claims denied for coding-related issues. As a Clinical Coding Analyst, you will play a critical role in  identifying and resolving coding discrepancies, ensuring  accurate and compliant coding practices, and  optimizing revenue generation. Your  expertise in clinical coding, coding guidelines, and claims processing will be instrumental in analyzing and resolving coding-related denials, thereby enhancing operational efficiency and financial performance.  

Company Overview:  

For over 20 years,  we’ve been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We  utilize our deep  expertise in  revenue cycle to help transform our client’s revenue cycle processes to achieve sustained reductions in denial rates.  

Key Responsibilities:  

• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers.  

• Identify coding discrepancies, documentation deficiencies, and other factors contributing to claims denials,  utilizing a thorough understanding of coding guidelines, industry standards, and regulatory requirements.  

• Collaborate with coding teams, healthcare providers, and revenue cycle stakeholders to obtain necessary documentation and information for claims resubmission.  

• Prepare and support  coding ‑ based appeals by developing clear clinical and coding justifications  

• Review medical records, payer policies, and coding guidelines to support appeal arguments  

• Conduct in-depth coding audits and analysis to  validate the accuracy, completeness, and compliance of coding practices, and ensure alignment with payer requirements.  

• Research and interpret coding guidelines, including updates from coding authorities, to ensure coding accuracy and compliance.  

• Maintain up-to-date knowledge of payer policies, medical necessity criteria, and reimbursement guidelines to accurately evaluate coding denials and appeals.  

• Compile and prepare detailed reports on coding-related denials,  identifying patterns, trends, and opportunities for process improvement.  

• Collaborate with the revenue cycle team to develop strategies and initiatives aimed at reducing coding-related denials and improving overall revenue cycle performance.  

• Stay informed about emerging coding trends, changes in coding guidelines, and industry best practices, and provide recommendations for updating coding processes and policies.  

• Participate in coding-related meetings, committees, and training sessions to share insights, contribute to problem-solving, and promote cross-departmental collaboration.  

Qualifications:  

• Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or similar certification  is required .  

• Experience: Minimum of 2-3 years of medical coding or auditing experience and experience with risk adjustment audits, clinical documentation improvement (CDI), and payer audits.  

• Knowledge of Coding Systems: Strong knowledge of ICD-10, CPT, and HCPCS coding systems, and familiarity with DRG, E/M coding.  

• Bachelor's degree: in Nursing, or any Medical or Health Information Management or  a related field.  

• Familiarity with medical necessity criteria, payer policies, and reimbursement methodologies.  

• Excellent understanding of revenue cycle processes , claims processing workflows, and  denials management.  

• Proficiency in using coding software, encoders, and electronic health record (EHR) systems .  

• Detail-oriented mindset with a high level of accuracy and organizational skills.  

• Effective communication and interpersonal skills to collaborate with coding teams, providers, and other stakeholders.  

• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.  

• Proficiency in using coding-related software and tools, as well as  a high level of computer literacy.  

• Join our dynamic team as a Clinical Coding Analyst and contribute to the resolution of coding-related denials, ensuring  accurate and compliant coding practices that maximize reimbursement and support  optimal healthcare delivery.  

Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.