HB Inpatient Denials Integrity Specialist
About The Position
This position analyzes and resolves coding-related PB and HB denials using CPT, HCPCS, ICD-10-CM, and modifiers. The specialist will identify root causes, patterns, and trends in denial and rejection codes, and collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims. Responsibilities include conducting chart reviews to validate documentation against billed services, preparing and supporting appeals by researching payer guidelines, coding standards, and coverage policies, and ensuring accurate, compliant coding and sequencing aligned with official guidelines and payer requirements. The role also involves tracking, documenting, and reporting denial resolutions, appeal outcomes, and coding quality issues, supporting compliance, quality assurance, and revenue integrity initiatives, and educating clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends. Additionally, the specialist will contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.
Requirements
- Associate degree or equivalent education and experience required.
- Coding credential required. A Coding Certification from American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) with relevant experience.
- 4 years of experience in expert-level hospital-based coding and experience in revenue cycle processes, health information workflows, and medical record auditing experience.
- Advanced knowledge of third-party reimbursement programs, state and federal regulatory issues, national and local coverage decisions, research related restrictions, and ICD-10-PCS/CM, CPT, and HCPCS coding classification systems.
- Advanced knowledge of medical terminology, anatomy, and physiology.
- Advanced ability to identify coding discrepancies and provide recommendations for improvement.
- Advanced ability to analyze trends and data and display them in a statistical reporting format.
- Advanced knowledge of care delivery documentation systems and related medical record documents.
- Advanced knowledge of Medicare, Medicaid, and commercial payer coding guidelines.
- Advanced knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.
- Advanced interpersonal and communication (oral and written) skills, including the ability to effectively collaborate with multiple departments.
- Advanced organization and prioritization skills; ability to manage multiple priorities in a stressful, fast-paced work environment.
- Advanced analytical skills, with great attention to detail.
- Self-motivated with initiative and strong sense of ethics.
- Ability to work independently and exercise independent judgment and decision making.
- Ability to meet deadlines while working in a fast-paced environment.
- Strong organizational skills and ability to work independently with limited guidance or direction.
- Effective critical thinking, creativity, problem solving and decision-making skills.
Nice To Haves
- Second Specialty credential preferred.
Responsibilities
- Analyze and resolve coding-related PB and HB denials using CPT, HCPCS, ICD-10-CM, and modifiers.
- Identify root causes, patterns, and trends in denial and rejection codes.
- Collaborate with billing, coding, and payer teams to correct, resubmit, and prevent denied claims.
- Conduct chart reviews to validate documentation against billed services.
- Prepare and support appeals by researching payer guidelines, coding standards, and coverage policies.
- Ensure accurate, compliant coding and sequencing aligned with official guidelines and payer requirements.
- Track, document, and report denial resolutions, appeal outcomes, and coding quality issues.
- Support compliance, quality assurance, and revenue integrity initiatives through issue monitoring and escalation resolution.
- Educate clinicians, coders, and staff by sharing findings and supporting targeted training based on denial trends.
- Contribute to operational and strategic initiatives, including denial avoidance strategies, work queue optimization, CARC code mapping, and technology-driven improvements.
Benefits
- Comprehensive suite of Total Rewards: benefits and well-being programs
- Competitive compensation
- Generous retirement offerings
- Programs that invest in your career development
- Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
- Premium pay such as shift, on call, and more based on a teammate's job
- Incentive pay for select positions
- Opportunity for annual increases based on performance
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
