Senior Coding Denials Management Specialist (HIM Inpatient) - HIM Financial - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

The Senior HIM Coding Denials Management Specialist is a seasoned inpatient coding professional or coding auditor responsible for triaging, identifying payer's reason for claim denials/rejections, analyzing, and resolving inpatient and outpatient coding-related insurance claim denials, rejections, and DRG downgrades in compliance with all applicable federal and state regulations. This role operates at the intersection of medical coding, billing, clinical documentation, and payer compliance, ensuring accurate claim submission, effective rebuttals & appeals, and optimal reimbursement. Under general supervision, the specialist reviews and triages payer-denial type, prepares and submits first- and second-level coding-related appeals, and conducts in-depth regulatory, coding, and clinical research to support rebuttals. The role collaborates closely with coding, billing, CDI, and clinical teams to resolve root causes of denials, implement corrective actions, creates denials reports/dashboards, and drive continuous revenue cycle improvement through data analysis and process monitoring.

Essential Duties:

• Denials Triage & Resolution * Review and triage PFS-related, coding-related, and clinical-related denials and DRG downgrades. * Independently manage and resolve coding-related inpatient and outpatient claim denials, rejections, and DRG downgrades. * Analyze payer denial rationale related to ICD-10-CM, ICD-10-PCS, CPT/HCPCS, MS-DRGs, APR-DRGs, APCs, and modifiers. * Interpret payer-specific payment methodologies and contractual payable/non-payable benefit structures.
• Appeals Management * Prepare, submit, and track first- and second-level coding-related appeals to Medicare, Medi-Cal, MACs, RACs, QIOs, and commercial payers. * Develop comprehensive rebuttal letters and appeal packages supported by clinical documentation, coding guidelines, and regulatory references. * Document all appeal activity, correspondence, and outcomes within coding and billing systems. * Coordinate follow-up with Patient Financial Services (PFS) regarding reimbursement outcomes.
• Regulatory, Coding & Clinical Research * Perform in-depth research using IPPS/OPPS Federal Register, NCDs, LCDs, NCCI edits, Official Coding Guidelines, AHA Coding Clinic, CPT Assistant, and related authoritative sources. * Ensure all work is compliant with federal and state coding laws, regulations, and payer policies. * Apply regulatory and coding guidance to defend coding decisions during audits and payer disputes.
• Root Cause Analysis & Process Improvement * Identify and trend recurring denial patterns and DRG downgrades. * Conduct root cause analysis to determine systemic coding, documentation, or workflow issues. * Develop and recommend corrective action plans in collaboration with coding, billing, CDI, and clinical teams. * Support documentation improvement initiatives by initiating queries through CDI when clarification is required.
• Reporting & Performance Monitoring * Develop and maintain reports to monitor denial volumes, trends, appeal outcomes, and success rates. * Utilize data to support performance improvement, education, and revenue cycle optimization initiatives. * Provide actionable insights to leadership to reduce future denials and improve coding accuracy.
• Communication & Collaboration * Serve as a liaison between coders, clinicians, CDI specialists, billing teams, PFS, and external payers. * Communicate professionally and effectively with internal stakeholders and external entities. * Provide timely written and verbal follow-up, including emails, documentation notes, and verbal discussions. * Maintain strong working relationships with physicians and leadership through clear, ethical, and solution-focused communication.
• Information Systems & Technology * Utilize and navigate EHR and coding systems efficiently, including: Cerner/PowerChart and Coding mPage Solventum/3M 360 Encompass (CAC/CRS) Solventum/3M HDM, HRM, and ARMS Core Soarian Financials and related PFS interfaces * Leverage system tools and embedded references to support accurate coding, denial resolution, and appeals processing.
• Perform other duties as assigned.

Required Qualifications:

• Req High School or equivalent
• Req Specialized/technical training Successful completion of college courses in Medical Terminology, Anatomy & Physiology and a certified coding course. Must possess a thorough knowledge of ICD/DRG coding and/or CPT/HCPCS coding principles, and the recommended American Health Information Management Association (AHIMA) coding competencies.

• Req 10 years Experience in ICD, CPT/HCPCS coding of inpatient & outpatient medical records in an acute care facility.
• Req Experience in using a computerized coding & abstracting database software and encoding/code-finder systems [e.g., 3M 360 Encompass/CAC & 3M Coding & Reimbursement System (CRS)].

• Req Working knowledge of CPT, HCPCs and ICD9 coding principles
• Req Organization/time management skills.
• Req Demonstrate excellent customer service behavior.
• Req Demonstrates excellent verbal and written communication skills.
• Req Able to function independently and as a member of a team

Preferred Qualifications:

• Pref 1 - 2 years Lead Experience.

Required Licenses/Certifications:

• Req AHIMA Certified Coding Specialist (CCS) only; or AAPC Certified Inpatient Coder (CIC) only; or either the CCS or CIC in conjunction with any one of the following national HIM credentials: 1. AHIMA Registered Health Information Technician (RHIT) 2. AHIMA Registered Health Information Administrator (RHIA) Successful completion of the hospital specific coding test - with a passing score of 90%. The coding test may be waived for former USC or agency/contract HIM Coding Dept. coders who historically/previously met the 90% internal/external audit standards of the previously held USC Job Code.
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)