Coding Denial Management Specialist

ESSENTIAL DUTIES AND RESPONSIBILITIES:

(85%) Resolve Post-Service Claim Denials

1. Investigate and resolve post-service claim denials involving diagnosis coding, CPT/HCPCS codes, modifiers, bundling, National Correct Coding Initiative (NCCI) edits, physician reading locations, Medicare localities, and other coding-related discrepancies.
2. Review medical records, physician orders, and diagnostic reports to validate coding accuracy and determine medical necessity support.
3. Interpret Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), commercial payer policies, and applicable coding guidelines.
4. Evaluate and implement appropriate diagnosis, procedure, and modifier corrections, including submission of corrected claims for payer reprocessing.
5. Research and resolve coding-related billing discrepancies, including split billing, duplicate charges, charge transfers between encounters, and referring/rendering provider corrections within established departmental workflows.
6. Develop accurate, evidence-based coding and medical necessity rationale to support reconsiderations and appeals prepared and submitted by the AR and Denials team.
7. Collaborate with internal teams to obtain necessary documentation, resolve complex denials, and escalate issues outside the scope of coding denial management.
8. Maintain accurate documentation of findings, coding determinations, corrective actions, and resolution activities.
9. Identify recurring denial patterns and opportunities to improve coding accuracy, workflows, and denial prevention through front end coding improvement, denial review efficiency, provider documentation improvement, or any other means.
10. Prioritize assigned inventory based on aging, reimbursement impact, filing deadlines, and operational priorities.
11. Meet established productivity, quality, accuracy, and turnaround time standards.

1. Participate in process improvement, education, and denial prevention initiatives.
2. Support expanded coding denial resolution activities, including the preparation of coding-related reconsiderations and appeals, as assigned.

1. High school diploma, or equivalent
2. Associate degree in Health Information Management, Healthcare Administration, or other related and relevant field; the equivalent in applicable experience may be considered in lieu of degree
3. Two (2) years' experience in professional medical coding and coding-related denial review or resolution
4. Experience reviewing clinical documentation and interpreting payer medical necessity requirements
5. Active professional medical coding certification, such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Radiology Certified Coder (RCC), or an equivalent and approved credential.
6. Strong knowledge of coding guidelines, clinical documentation standards, and payer reimbursement policies
7. Working knowledge of ICD-10-CM, CPT, HCPCS, modifiers, and applicable coding guidelines
8. Proficiency in using healthcare billing or practice management systems
9. Proficiency in Microsoft Windows and Office Suite; Outlook, Teams, Excel, Word, PowerPoint, etc.
10. Valid driver's license and proof of current insurance is required for the team member to personally drive a vehicle for company business (regardless of whether it's a company or personal vehicle)

Preferred:

1. Bachelor's degree in Health Information Management, Healthcare Administration, or other related and applicable field
2. Experience in diagnostic radiology coding and reimbursement.
3. Experience resolving post-service medical necessity and coding denials
4. Familiarity with Medicare LCDs (Local Coverage Determinations), NCDs (National Coverage Determinations), NCCI (National Correct Coding Initiative) edits, and commercial payer policies.
5. Experience supporting coding-related reconsiderations and appeals.

RAYUS is committed to delivering clinical excellence in communities across the U.S., driven by our passion for and superior service to referring providers and patients. RAYUS Radiology is built on our brilliant medicine, brilliant team, brilliant technology and services - all to provide the highest level of patient care possible.

We bring brilliance to health and wellness. Join our team and shine the light on Radiology Services! RAYUS Radiology is an EO Employer/Vets/Disabled.

We offer benefits (based on eligibility) including medical, dental and vision insurance, 401k with company match, life and disability insurance, tuition reimbursement, adoption assistance, pet insurance, PTO and holiday pay and many more! Visit our career page to see them all www.rayusradiology.com/careers.

DailyPay implementation is contingent upon initial set-up period.