Medical Coding Appeals Analyst

About This Role

This role ensures accurate claim adjudication by translating medical policies, reimbursement policies, and clinical editing policies into effective reimbursement criteria. It requires reviewing medical documentation, performing code updates, and responding to system inquiries and appeals.

Responsibilities

• Review medical record documentation for Evaluation and Management, CPT, HCPCS, and ICD-10 codes
• Review and conduct clinical research for company, CMS, and competitor medical and reimbursement policies, and editing rules
• Translate medical policies into reimbursement rules
• Perform CPT/HCPCS code and fee schedule updates, analyzing new codes for coverage and implications for system edits
• Coordinate research and respond to system inquiries and appeals
• Conduct research of claims systems and system edits to identify adjudication issues and audit claims for accuracy
• Perform pre-adjudication claims reviews to ensure proper coding
• Prepare correspondence to providers regarding coding and fee schedule updates
• Train customer service staff on system issues
• Work with provider contracting staff for new/modified reimbursement contracts

Requirements

• BA/BS degree or equivalent experience
• Minimum of 2 years related experience
• Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification

Qualifications

• BA/BS degree or equivalent combination of education and experience
• 2+ years related experience

Nice to Have

• CEMC certification
• RHIT certification
• CCS certification
• CCS-P certification

Skills

* Required skills

Benefits

Certifications