Medical Coding Appeals Analyst

Elevance Health•Tampa, FL

19h•Hybrid

About The Position

The Medical Coding Appeals Analyst ensures accurate adjudication of claims by translating medical, reimbursement, and clinical editing policies into effective and accurate reimbursement criteria. This role involves reviewing medical record documentation for Evaluation and Management, CPT, HCPCS, and ICD-10 codes. The analyst researches company-specific, CMS-specific, and competitor medical and reimbursement policies, conducts clinical research, and analyzes data to support the development or revision of enterprise reimbursement policies. Key responsibilities include translating medical policies into reimbursement rules, performing CPT/HCPCS code and fee schedule updates, and analyzing new codes for coverage and system implications. The analyst also coordinates research and responds to system inquiries and appeals, audits claims adjudication for accuracy, and performs pre-adjudication claims reviews. Additionally, they prepare correspondence to providers regarding coding and fee schedule updates, train customer service staff on system issues, and collaborate with provider contracting staff for new or modified reimbursement contracts. This position offers virtual full-time work, with the exception of required in-person training sessions, providing flexibility and supporting work-life integration.

Requirements

Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background.
Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required.

Nice To Haves

CEMC, RHIT, CCS, CCS-P certifications preferred.

Responsibilities

Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code.
Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
Translates medical policies into reimbursement rules.
Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
Coordinates research and responds to system inquiries and appeals.
Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
Perform pre-adjudication claims reviews to ensure proper coding was used.
Prepares correspondence to providers regarding coding and fee schedule updates.
Trains customer service staff on system issues.
Works with providers contracting staff when new/modified reimbursement contracts are needed.