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AR Coding Denials Representative

Job ID 149508 Date posted 09/12/2018

Position Summary:
Identifies, reviews, and interprets third party payments, adjustments and coding denials for all professional services. Reviews provider documentation in order to determine appropriate coding and initiate corrected claims and appeals. Duties include hands on coding, documentation review and other coding needs for ICD-9, ICD-10. Works directly with the Billing Supervisor and Coding Manager to resolve complex issues and denials through independent research and assigned projects.

Essential Duties & Responsibilities including but not limited to:
1. Provides review and/or coding of any coding related denied professional services for appropriate use of CPT, ICD-9, ICD-10, HCPCS, Modifier usage/linkage.
2. Monitors days in A/R and ensures that they are maintained at the levels expected by management. Analyzes work queues and other system reports and identifies denial/non-payment trends and reports them to the Billing Supervisor.
3. Responds to incoming insurance/office calls with professionalism and helps to resolve callers? issues, retrieving critical information that impacts the resolution of current or potential future claims.
4. Establishes relationships and maintains open communication with third party payor representatives in order to resolve claims issues.
5. Reviews claim forms for the accuracy of procedures, diagnoses, demographic and insurance information, as well as all other fields on the CMS 1500.
6. Reviews and corrects all claims/charge denials and edits that are communicated via Epic, Explanation of Benefits (EOB), direct correspondence from the insurance carrier or others and uses information learned to educate PFS and office staff to reduce future denials and edits of the same nature. Initiates claim rebilling or corrections and obtains and submits information necessary to ensure account resolution/payments.
7. Identifies invalid account information (i.e.: coverage, demographics, etc.) and resolves issues.
8. Evaluates delinquent third party accounts and processes based on established protocols for review, payment plan or write-off.
9. Reviews/updates all accounts for write-offs and refunds.
10. Keeps informed of all federal, state, and managed care contract regulations, maintains working knowledge of billing mechanics in order to properly ascertain patients? portion due.
11. Completes all assignments per the turnaround standards. Reports unfinished assignments to the Billing Supervisor.
12. Handles incoming department mail as assigned.
13. Attends meetings and serves on committees as requested.
14. Maintains appropriate audit results or achieves exemplary audit results. Meet productivity standards or consistently exceeds productivity standards.
15. Provides and promotes ideas geared toward process improvements within the Central Billing Office.
16. Assists the Billing Supervisor with the resolution of complex claims issues, denials and appeals.
17. Completes projects and research as assigned.
18. Provides feedback and participates as the coding representative for the Patient Financial Services Department on the Revenue Cycle teams.
19. Confers regularly with the Coding department through regular departmental staff meetings, one-on-one meetings to review and discuss coding denials and education.

Secondary Functions:
1. Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
2. Complies with policies and procedures as they relate to the job. Ensures confidentiality of patient, budget, legal and company matters.
3. Exercises care in the operation and use of equipment and reference materials. Performs routine cleaning and preventive maintenance to ensure continued functioning of equipment. Maintains work area in a clean and organized manner.
4. Refers complex or sensitive issues to the attention of the Billing Supervisor to ensure corrective measures are taken in a timely fashion.
5. Observes irregularities in the cash/denial posting process and reports them immediately to the Billing Supervisor.
6. Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
7. Assists other staff as required in the completion of daily tasks or special projects to support the department?s efficiency.
8. Performs similar or related duties as assigned or directed.

Education & Professional Development
1. Researches and stays updated and current on CMS (HCFA), AMA and Local Coverage Determinations (LCD?s), or Local Medical Review Policies (LMRP's) to ensure compliance with coding guidelines.
2. Stays current on quarterly CCI Edits, bi-monthly Medicare Bulletins, Medicare's yearly fee schedule, Medicare Website, and specialty newsletters.
3. Makes guidelines available via, paper, on-line access, web access, or any other means provided by manager.


High School diploma or equivalent, plus additional specialized training associated attainment of a recognized Coding Certificate

Licensure, Certification & Registration:
CPC (Certified Professional Coder through AAPC) or CCS-P (Certified Coding Specialist Physician Based through AHIMA)

1-2 years of experience in billing, coding, denial management environment related field.

Skills, Knowledge & Abilities:
- Ability to work independently and take initiative
- Good judgment and problem solving skills
- Excellent organizational skills
- Ability to interact and collaborate effectively and tactfully with staff, peers and management.
- Ability to promote team work through support and communication.
- Ability to accept constructive feedback and initiate appropriate actions to correct situations.
- Ability to work with frequent interruptions and respond appropriately to unexpected situations.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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