At Houston Methodist, the Coding Charges & Denials Specialist is responsible for coordinating and monitoring the coding specific clinical charges and denial management and appeals process in a collaborative environment with revenue cycle management and clinical partners at various Houston Methodist facilities. This position will be responsible for working assigned specialties and combines clinical knowledge to reduce financial risk and exposure caused by front end claim edits and retrospective denial of payments for services provided. This position will collaborate with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service inquiries. Additionally, this position will collaborate with key stakeholders and assist in developing appeal strategies to include reference material for staff, letter templates, and regular feedback for revenue cycle coding staff; and functions as clinical subject matter expert related to coding denials and appeals.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Communicates openly in a transparent and professional demeanor during all interactions with customers and co-workers while providing clear and concise communication of trending and findings to both front line team members and senior executives.

• Communicates to partners, revenue cycle staff, customers, and third party payers by telephone, in meetings, email, and other necessary forms of communication in a clear, effective, and timely manner while additionally providing proactive updates on initiatives that involve time and effort from peers and other employees.

• Functions as an educational liaison to clinical staff and revenue cycle staff as needed on payer denials, denial reason and trending, interpretation of payer manuals, medical policies, and local/national coverage determinations.

SERVICE ESSENTIAL FUNCTIONS

• Performs data mining and reporting activities that identify net positive impactful opportunities in denials and adjustments for the individual facilities and the system.

• Works assigned claim edit and follow up work queues and meets the assigned productivity standards on a daily basis as well as assigned patient account work queues and responds with resolutions within the expected time frame.

• Acts as a liaison for issues affecting various teams (coding, revenue integrity, accounts receivable (AR) follow up, etc.) of the revenue cycle while also providing support when IT related or systematic changes are needed.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Analyzes data from various sources (medical records, claims data, payer medical policies, etc.), determines the causes for denials of payment and partners with management to implement strategies to prevent future denials.

• Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical records submission.

• Performs timely review of medical records and remittances for denials in order to determine root cause and appropriateness.

FINANCE ESSENTIAL FUNCTIONS

• Partners with revenue cycle leadership and peers and clinical operations to reduce denials. This includes reviewing claim edits and denials and/or inquiries referred from other departments and assists in identifying root causes.

• Investigates the validity of the reasons for the denials and determines the need for or feasibility of submitting appeals.

• Works with revenue cycle management and staff to ensure claim edit/denial trending data is accurate and that all metrics are reported appropriately including specific current procedural terminology (CPT)/healthcare common procedure coding system (HCPCS), denial reasons, and appeals. Monitors recovery of payments and trends to identify corrective measures needed to prevent future edits/denials.

• Analyzes claim edits/denials to identify new trends, opportunities, and educational feedback as needed. This includes, but not limited to, feedback to coding, clinical service areas, physicians, and other revenue cycle staff. Makes recommendations to revenue cycle leadership on operations and root causes and assists in development of strategies to avoid future claim edits and denials.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Provides education to revenue cycle team and attends monthly billing staff meetings as appropriate.

• Pursues ongoing professional growth and development to maintain coding certification while remaining current on all coding and regulatory updates in addition to participating in educational activities.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

WORK EXPERIENCE

• Five years of certified coding experience with coding denials

• Accounts receivable follow up experience preferred

LICENSES AND CERTIFICATIONS - REQUIRED

• CPC - Certified Professional Coder (AAPC) or
• CCS - Certified Coding Specialist (AHIMA) or
• An approved Specialty Society Coding Certification

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Demonstrates the ability to think critically, work independently, and be self-motivated for the role

• Experience with computer database management and Microsoft Office software

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform Yes
• Scrubs Yes
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes

Houston Methodist Specialty Physician Group - As one of the nation’s leading hospitals and academic medical centers Houston Methodist has brought together some of the nation’s leading experts in multiple specialties to serve our patients.  As part of Houston Methodist Specialty Physician Group (HMSPG), these specialists not only provide excellent clinical care, but are on the forefront of research, developing leading-edge technologies and treatments, and teaching the medical pioneers of tomorrow.  This combination of clinical service, research and academics ensures patients have access to the latest in treatments and technologies while providing the best in comprehensive patient care.  Established as a non-profit corporation and certified by the Texas State Board of Medical Examiners, HMSPG enables physicians to maintain autonomy with respect to their clinical practice while growing their practice within an academic environment.