Houston, Texas

JOB SUMMARY

At Houston Methodist, the Coding Charges & Denials Specialist is responsible for coordinating and monitoring the coding specific clinical charges and denial management and appeals process in a collaborative environment with revenue cycle management and clinical partners at various Houston Methodist facilities. This position will be responsible for working assigned specialties and combines clinical knowledge to reduce financial risk and exposure caused by front end claim edits and retrospective denial of payments for services provided. This position will collaborate with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service inquiries. Additionally, this position will collaborate with key stakeholders and assist in developing appeal strategies to include reference material for staff, letter templates, and regular feedback for revenue cycle coding staff; and functions as clinical subject matter expert related to coding denials and appeals.

PRIMARY JOB RESPONSIBILITIES

Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE - 25%

  1. Communicates openly in a transparent and professional demeanor during all interactions with customers and co-workers while providing clear and concise communication of trending and findings to both front line team members and senior executives. (EF)
  2. Communicates to partners, revenue cycle staff, customers, and third party payers by telephone, in meetings, email, and other necessary forms of communication in a clear, effective, and timely manner while additionally providing proactive updates on initiatives that involve time and effort from peers and other employees. (EF)
  3. Functions as an educational liaison to clinical staff and revenue cycle staff as needed on payer denials, denial reason and trending, interpretation of payer manuals, medical policies, and local/national coverage determinations. (EF)

SERVICE - 20%

  1. Performs data mining and reporting activities that identify net positive impactful opportunities in denials and adjustments for the individual facilities and the system. (EF)
  2. Works assigned claim edit and follow up work queues and meets the assigned productivity standards on a daily basis as well as assigned patient account work queues and responds with resolutions within the expected time frame. (EF)
  3. Acts as a liaison for issues affecting various teams (coding, revenue integrity, accounts receivable (AR) follow up, etc.) of the revenue cycle while also providing support when IT related or systematic changes are needed. (EF)

QUALITY/SAFETY - 25%

  1. 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. (EF)
  2. Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical records submission. (EF)
  3. Performs timely review of medical records and remittances for denials in order to determine root cause and appropriateness. (EF)

FINANCE - 20%

  1. Partners with revenue cycle leadership and peers and clinical operations to reduce denials. This includes reviewing claim edits and denials and/or inquiries referred from other departments and assists in identifying root causes. (EF)
  2. Investigates the validity of the reasons for the denials and determines the need for or feasibility of submitting appeals. (EF)
  3. Works with revenue cycle management and staff to ensure claim edit/denial trending data is accurate and that all metrics are reported appropriately including specific current procedural terminology (CPT)/healthcare common procedure coding system (HCPCS), denial reasons, and appeals. Monitors recovery of payments and trends to identify corrective measures needed to prevent future edits/denials. (EF)
  4. Analyzes claim edits/denials to identify new trends, opportunities, and educational feedback as needed. This includes, but not limited to, feedback to coding, clinical service areas, physicians, and other revenue cycle staff. Makes recommendations to revenue cycle leadership on operations and root causes and assists in development of strategies to avoid future claim edits and denials. (EF)

GROWTH/INNOVATION - 10%

  1. Provides education to revenue cycle team and attends monthly billing staff meetings as appropriate. (EF)
  2. Pursues ongoing professional growth and development to maintain coding certification while remaining current on all coding and regulatory updates in addition to participating in educational activities. (EF)

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.



EDUCATION REQUIREMENTS

o High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

EXPERIENCE REQUIREMENTS

o Five years of certified coding experience with coding denials

o Accounts receivable follow up experience preferred

CERTIFICATIONS, LICENSES AND REGISTRATIONS REQUIRED

o Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC), Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA), or an approved Specialty Society Coding Certification

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

o Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

o Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

o Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

o Demonstrates the ability to think critically, work independently, and be self-motivated for the role

o Experience with computer database management and Microsoft Office software

 

SUPPLEMENTAL REQUIREMENTS

 

Work Attire Yes/No

Uniform Yes

Scrubs Yes

Business professional Yes

Other (dept approved) No

 

On-Call* Yes, on a regular basis (for Non-Exempt or Exempt jobs)

 

*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.

 

Travel**

May require travel within Yes

Houston Metropolitan area

 

May require travel outside Yes

of Houston Metropolitan area

 

**Travel specifications may vary by department.

 

Please note any other special considerations to this job: __________________________

Company Profile:

As one of the nation’s leading hospitals and academic medical centers, Houston Methodist has brought together some of the nation’s leading experts in multiple specialties to serve our patients. Houston Methodist Specialty Physician Group employs over 800 physicians at more than 150 locations across Houston. Our specialists are on the forefront of research, developing leading-edge technologies and treatments, and teaching the medical pioneers of tomorrow. The combination of clinical service, research and academics ensure patients have access to the latest treatments and technologies while providing the best comprehensive patient care.

Houston, Texas

At Houston Methodist, Leading Medicine is more than a description of what we do; it's who we are. We take our responsibility as Houston's premier health care system seriously, and with a national reputation for excellence in patient care, innovation and research, we hold ourselves and the careers we build to a higher standard. Our culture is diverse, dynamic and challenging. We believe in our I Care Values and conduct ourselves with Integrity, Compassion, Accountability, Respect for others and a commitment to Excellence. Discover the difference for yourself and join Houston Methodist.

You can click on the video links below to learn more!

·  About Houston Methodisthttps://www.youtube.com/watch?v=ClN3mmKT0EI

·  Nursing at Houston Methodisthttps://www.youtube.com/watch?v=EUfmVeansTo

·  Houston - Best City to Live Inhttps://www.youtube.com/watch?v=MzLQzGBjHJw