Retrospective Appeals Coder

UPMC

11d•Remote

About The Position

UPMC Corporate Revenue Cycle is hiring a Retrospective Appeals Coder to support local coding departments by initiating retrospective appeals for coding denials. The role uses coding expertise and knowledge of payer regulations to assess whether criteria are present to recover denied reimbursement through an appeal. The position is remote and works Monday through Friday.

Requirements

Five years of coding experience.
Extensive knowledge of DRG/APC, ICD-9/10, and CPT/HCPCS classifications and coding of diagnoses and procedures.
Knowledge of medical terminology, human anatomy and physiology, pharmacology, and pathology.
Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) credential.
Act 34 clearance.

Nice To Haves

Bachelor's degree in Business Administration or a related field, or Registered Record Administrator (RAA), preferred.
Clinical Documentation Specialist or clinical validation of coding experience, preferred.
Prior appeal or grievance experience, preferred.

Responsibilities

Investigate retrospective denials and identify root causes to help determine system-wide coding needs; review and resolve pre-bill edits as needed.
Maintain current knowledge of regulatory guidelines related to retrospective appeals.
Serve as a liaison between coding departments and payors, facilitating payor and physician contact when indicated.
Maintain collaborative relationships with coding management and appeal departments at payor organizations.
Collaborate with other departments to identify information needed to support retrospective appeals.
Prepare written appeal letters as appropriate, incorporating supporting documentation such as medical criteria and state regulations.
Review coding for cases referred for retrospective appeals or audits and determine whether an appeal is warranted.
Act as a liaison to other departments regarding the retrospective appeal process.
Provide ongoing education to coding and other departments about the appeal process.
Ensure the appeal process is followed to achieve timely and appropriate appeals.
Identify and assign a root cause to each case so denial reasons can be tracked.
Monitor and evaluate opportunities to improve the retrospective appeal process.