Hospital Coding Denials Integrity Specialist

Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying the accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data such as discharge disposition.

Ensures accurate coding for outpatient, day surgery, and inpatient records, and verifies codes and sequencing for claims according to AHA coding guidelines, CPT Assistant, AHA Coding Clinic, and national and local coverage decisions.

Collaborates with coding leadership to review records with focused diagnosis and procedure codes, APCs, DRGs, and OIG work plan targets to support compliance and identify documentation that affects code assignment.

Reviews encounters flagged for second-level review, including HACs, complications, core measures, and other identified records, and evaluates risk adjustment, severity, and mortality assignment.

Supports the Clinical Documentation Improvement and Hospital Coding alignment process by reviewing mismatched DRG assignments, determining the correct DRG based on coding guidelines, and providing rationale and follow-up to clinical documentation staff.

Participates in hospital coding denial and appeal processes, including review of third-party payer claim denials, determining whether appeals should be written, and supporting rebilling for overpayment or underpayment denials to ensure appropriate reimbursement.

Investigates and resolves edits and inquiries from the billing office or patient accounts to prevent delays in claim submission related to coding questions.

Maintains continuing education and credentials while staying current on trends, legislative issues, and technology in Health Information Management.