Job Description

Overview: The individual in this position on behalf of the entire Piedmont System will be responsible for managing the administrative appeal of reimbursement claims denied by Medicare or Medicaid on the grounds that the medical coding was incorrect. These duties involve coordination of activities with the managers of coding at each of the Piedmont affiliated hospitals and physician practices as well as the Senior Director of Government Appeals. The incumbent must maintain a high level of understanding of DRGs and MS/DRGs. ICD-9-CM Official Guidelines for Coding and Reporting, American Hospital Association Coding Clinic guidelines, federal guidelines for coding Medicare inpatient records, state guidelines for coding Medicaid records, Utilization Review ("UR") regulations and Medicare guidelines regarding medical necessity, inpatient, outpatient and observation. In the context of managing the appeals, the incumbent will be responsible for resolving differences of opinions among coders as to the most appropriate code. The incumbent will be responsible for preparing the coding appeals; performing a detailed review, analysis and extraction of clinical and coding information from patient medical records and drafting effective narratives for Medicare and Medicaid appeals briefs in support of denied cases throughout appeals at all levels of the government appeals process. In addition, the incumbent will be qualified and available to testify in appeal hearing before an administrative law judge as an expert in medical coding. Responsibilities: The individual in this position on behalf of the entire Piedmont System will be responsible for managing the administrative appeal of reimbursement claims denied by Medicare or Medicaid on the grounds that the medical coding was incorrect. These duties involve coordination of activities with the managers of coding at each of the Piedmont affiliated hospitals and physician practices as well as the Senior Director of Government Appeals. The incumbent must maintain a high level of understanding of DRGs and MS/DRGs. ICD-9-CM Official Guidelines for Coding and Reporting, American Hospital Association Coding Clinic guidelines, federal guidelines for coding Medicare inpatient records, state guidelines for coding Medicaid records, Utilization Review ("UR") regulations and Medicare guidelines regarding medical necessity, inpatient, outpatient and observation. In the context of managing the appeals, the incumbent will be responsible for resolving differences of opinions among coders as to the most appropriate code. The incumbent will be responsible for preparing the coding appeals; performing a detailed review, analysis and extraction of clinical and coding information from patient medical records and drafting effective narratives for Medicare and Medicaid appeals briefs in support of denied cases throughout appeals at all levels of the government appeals process. In addition, the incumbent will be qualified and available to testify in appeal hearing before an administrative law judge as an expert in medical coding. Qualifications:

Education

Bachelor's Degree Bachelor's degree Required In lieu of degree, six (6) years of relevant work experience will be accepted in addition to the experience requirement Required Coding Certificate program (AHIMA accredited) Preferred Master's degree Master's degree Preferred

Work Experience

5 years of inpatient coding experience and of DRG-MS/DRG auditing experience in a healthcare setting Required Experienced medical record/DRG coder/auditor with a working knowledge of ICD-10 guidelines, case management, government and contracted payers Required Must be experienced in clinical, coding and patient financial services software such as 3-M Encoder, SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites Required In lieu of degree (, a total of eleven (11) years of experience ) Required Experience in coding at a multi-facility organization and remote coding experience is a plus Required Previous experience writing DRG Appeals Preferred Previous experience with RAC claims denials Preferred

Licenses and Certifications

None Required

Additional Licenses and Certifications

One or more certifications - Registered Health Information Management Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), CCA, CCS-P, CPC, CPC-H Required
Business Unit : Name: Piedmont Healthcare