Position Summary:
The Director, Coding Audits and Appeals is responsible for providing strategic and daily operational management of a team of Coding Denials Auditors. This individual will establish and maintain standards of professional competence, monitoring, and ensuring productivity and quality benchmarks are within acceptable guidelines. The Director, Coding Audits and Appeals combines clinical, business, and regulatory knowledge skills to identify, report and communicate coding denial data trends to internal and external stakeholders and is responsible for proactively initiating educational opportunities for each member of the team.
Key Responsibilities

• Oversees the daily operations of the Coding Denials Auditing team including workload and staffing; hiring, disciplining and performance appraisals; training and monitoring of work.
• Provides leadership and management to the Coding Denials Auditors
• Coaches, motivates, trains, and guides team members
• Monitors daily progress and ensures productivity and quality standards are met
• Arranges relevant and current educational opportunities that meet industry standards
• Leads the team to achieve project milestones and department objectives
• Conducts performance reviews and developmental programs of the team members
• Plans, delegates, and/or allocates work of the team in the Coding Denials Audit process
• Develops best-practice guidelines for the coding team that aligns with company vision/overall goals
• Leads the team in measuring, monitoring, and optimizing performance. Delivers performance reporting to key leadership with corrective action plan for variances when appropriate.
• Conducts complex coding audits of post-claim denials or post-payment reviews to determine appropriateness of procedure and diagnosis codes billed based on documentation provided for outpatient, inpatient, and professional fee claims.
• Audits billing for accuracy to ensure compliance of proper billing and coding procedures of third-party carriers and to ensure complete and accurate reimbursement.
• Maintains current working knowledge of all related HIPAA and coding compliance regulations and ensures staff adherence to these requirements.
• Conducts trend analyses to identify patterns and variations across clients. Creates ad hoc reports for internal leadership and external clients based on trends found on an as needed basis.
• Reviews and analyzes current audit information to educate the team and colleagues within the revenue cycle and throughout the organization
• Participates in the evaluation and selection of vendor relationships for health information management coding products/services.
• Responsible for independent problem solving, risk mitigation and contingency plans.
• Serves as a subject matter expert resource company wide to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines, and regulatory requirements.
• Builds and maintains strategic and tactical working relationships, an actively shares and collaborates with other departments and key stakeholders to drive goals and desired outcomes.
• Communicates clearly, proactively, and concisely with key stakeholders
• Other duties as required.

Requirements and Qualifications

• Bachelor's Degree in Health Information Management or related field
• Required Licenses/Certifications (one of the following):
• CPC- Certified Professional Coder - AAPC
• COC- Certified Outpatient Coder - AAPC
• CIC - Certified Inpatient Coder - AAPC
• CCA - Certified Coding Associate - AHIMA
• CCS - Certified Coding Specialist - AHIMA
• RHIT - Health Information Technician - AHIMA
• 7 years of coding auditing experience with a demonstrated background in hospital (outpatient and/or inpatient), and orthopedic physician coding and reimbursement
• 3-5 years experience in Management/Supervisory role
• 3 years of hospital Revenue Cycle or other healthcare services or HIM operations experience
• Deep understanding of medical coding, billing processes and associated terminology, and regulations around reimbursement and compliance.
• Demonstrated competency in coding review and knowledge of required data elements of medical billing claims forms (UB-04/837i, CMS-1500/837p)
• Ability to research, interpret, and clearly communicate regulatory requirements
• Practices effective decision making by relating and comparing relative information, identifying key issues, then committing to an action plan that considers resources, constraints, and organizational values.
• Independently initiates prompt proactive steps towards problem resolution.
• Must have strong verbal and written communication skills to facilitate relationships with various key internal personnel including Operational and Executive leadership and external clients.
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
• Equivalent combination of education and experience will be considered
• Must have strong computer proficiency and understand how to use basic office applications, including MS Office (Word, Excel, and Outlook).
• Regular and predictable attendance.

Special Considerations and Prerequisites

• Experience with complex payers such Workers' Compensation, Veterans Administration, Motor Vehicle Accident or Out-of-State Medicaid claims is strongly preferred
• Ability to communicate audit outcomes and testing results with other staff within the company who are both medically and non-medically oriented
• General computer skills including use of Optum Encoders Microsoft Excel, Outlook, Zoom as well as common medical coding software programs
• Familiarity with healthcare documentation systems
• Strong verbal, written and interpersonal communication and customer service skills
• Strong organizational and time management skills with the ability to manage workload independently
• Ability to think critically and make decisions within individual role and responsibility