Team Lead Physician Coding Denials

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Work Shift

Day (United States of America)

Job Summary:

The Physician Coding Denials Team Lead is responsible for assisting and leading the physician coding denials team in the review and appeal of coding denials for all assigned professional service claims related to CPT, Diagnosis, modifier, surgical and other specialty related coding denials that need review, reconsideration, and appeals. Closely works with Charge Coding & Revenue Management leaders and Account Resolution teams to provide feedback to providers/practices to improve clinical documentation and facilitate ongoing documentation and pre-bill coding improvement. Responsible for answering questions from the team, identifying trends, managing wq volumes, aging, and prioritize inventory for the team. The Physician Coding Denials Team Lead will perform Quality Assurance audits for the Specialist to foster a culture of continuous quality improvement. The Team Lead is also responsible to assist in training and cross training of new and current team members to expand their coding specialty knowledge, strengths, and skill set. Monitor's denial work queues within Epic (Electronic Health Record) to ensure timely appeal deadlines are met. Uses analytical skills to identify trends in payer denials and translates this information into Charge Review edits that will be used to prevent future denials. Assists in development and implementation of training for charge capture specialists and other physician coding denials specialists. The Physician Coding Denials Team Lead monitors key metrics and reports to ensure all activities are being completed by staff timely and accurately, including but not limited to team inventory and individual productivity reporting. The Team Lead oversees the Specialists and other staff of the MGBO Physician Coding Denials team, oversees the daily maintenance, regular updates, and coordinates all changes implemented in the MGBO. This position is also responsible for organizing, scheduling, and supervising staff to ensure adequate coverage, as well as prompt responses to issues, concerns, and/or complaints. The Physician Coding Denials Team lead will also participate in the interviewing, onboarding and training of new team members.

Core Responsibilities And Essential Functions:

Coding Denials Management * Identify major reasons for denials root causes related to specialty services. (Diagnosis, procedure codes, modifiers, etc.). * Work collaboratively with charge coding and revenue management to provide coding and documentation feedback to practices/providers. * Utilize Epic to review account denial audits and perform trend analyses to identify patterns and variations in coding denials and practices. * Maintain open communication with Wellstar Medical Group providers and practices to facilitate denial/appeals process. * Review clinical records to identify overcharges, undercharges or charges that necessitate additional documentation. * Research and analyze charge and coding requirements for new services and technology. * Consistently meet current productivity and quality standards as assigned by department manager in ensuring accurate account follow-up. * Analyze, verify, and work with departments to modify charging/documentation procedures for high-risk areas * Develop and implement training required to educate Physician Practices on the changes, updates, and additions to charge review. * Provide individual contribution to the overall team effort of achieving the department goals and key performance indicators. * Oversee the testing of assigned options on department specific software applications, pathways, or enhancements * Ensure all staff are assigned the appropriate functions and have access to the proper department software application pathways * Contribute to the process of selection, development, and implementation of new software applications Team Leadership * Follow department guidelines for lunch, breaks, requesting time off, and shift assignments. * Demonstrate knowledge of the health system HIPAA privacy standards and ensure compliance with system PHI privacy practices. * Follow the health systems general Policy and Procedures, the Departments Policy and Procedures, and the Emergency Preparedness Procedures. * Follow JCAHO and outside regulatory agencies mandated rules and procedures. * Participate in the testing for assigned software applications, including verification of field integrity. * Ensure that staff members receive the appropriate training on how to perform their job functions, including in the applicable IT systems * Help set measurable productivity and quality standards that are benchmarked to an industry standard or internal standard * Facilitate regular staff huddles and/or meetings to communicate departmental and organizational issues, goals, achievements, and changes * Recommend, set up, and enforce cross-training schedules to ensure more than one member of the staff can perform each job function * Ensure updated payer bulletins, communications, department information, and policy and procedure changes are communicated and discussed in a timely manner with the appropriate staff members * Assign work to the staff, reviewing output of the staff for accuracy and completeness. Recommend workflow and department procedural changes to the Department Manager * Enforce Department and Facility policies, procedures and practices * Aid in overseeing and enforcing departmental compliance with outside regulatory agency rules and procedures. Report any deviations, violations, or problems to the Privacy Officer, notifying the Department Director * Approve and track all assigned staff members sick time or vacations requests in accordance with department policy and procedures. Schedule and maintain staff lunch and breaks * Review and approve timecards of assigned staff, displaying an effective knowledge of payroll practices and procedures * Perform other duties and responsibilities as assigned. Analysis and Interpretation of Trends * Identify opportunities for system and process improvement and submit to management. * Working with MGBO Edit Committee, physician coding compliance and Epic Connect, translate identified trends into Epic charge review rules. * Evaluates and adheres to clinical and billing policies, guidelines, and regulations of both commercial and governmental payors. * Appeals denials or instructs the resubmission of claims based on compliant medical record documentation and Wellstar Medical Group/MGBO policies and procedures. * Asses need for formal appeals of all clinical denials including but not limited to preauthorization of practice encounters and procedures, and for retroactive recovery reviews regarding medical necessity and limited billing compliance. Professional Communication * Communicate with all internal contacts in a professional manner including providers, practice staff, co-workers, management, and clinical staff. * Communicate with all external contacts in a professional manner including representatives from third party payor organizations. * Interact with internal customers/departments including HIM, Charge Coding and Revenue Management, Patient Access and the Single Business Office in a professional manner to achieve revenue cycle department accounts receivable goals and objectives. * Assure patient privacy and confidentiality as appropriate or required. * Initiate communication with peers about changes in payor policies and internal policies and procedures. * Prepare appeal letters that are specific, concise, and conclusive; providing payors with appropriate clinical documentation as needed. * Provide feedback to physicians, providers and management in a timely and professional manner. Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

High school diploma equivalent from accredited institution Associate's Degree in Health Information, Healthcare, Business or Medical Office Administration Bachelor's Degree in Health Information, Healthcare, Business or Medical Office Administration

Required Minimum License(S) And Certification(S):

All certifications are required upon hire unless otherwise stated.

• CPC - Cert Prof Coder
• CRCR - Certified Revenue Cycle Rep within 1 Year

Additional License(S) And Certification(S):

Certified Professional Biller Preferred or Certified Professional Medical Auditor Preferred Certified Professional Biller or Certified Professional Medical Auditor within 180 Days Required

Required Minimum Experience:

Minimum 3 years of Healthcare Account Resolution, Follow-up and Denials experience Required and Minimum 2 years of experience in Physician billing, including professional coding experience Required

Required Minimum Skills:

High level problem solving, analytical and investigational skills to research and resolve denied accounts. Technical skills to include Microsoft Office (Word, Excel, PowerPoint, Teams), EMR systems (Epic), graphs and tables experience and personal computers. Strong time management skills to independently manage multiple priorities and a heavy workload. Demonstrated flexibility to perform other tasks as needed in an active work environment with changing work needs. Ability to prioritize assignments to meet deadlines. Proven communication skills and positive motivational skills. Medical terminology and or anatomy/physiology, ICD-10, E/M coding, CPT coding and CPT modifiers. Understand governmental and commercial payor compliance regulations.

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