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Denials Coder Prevention Associate in Alpharetta, GA at CIOX Health

Date Posted: 8/11/2018

Job Snapshot

Job Description

Job purpose:

The purpose of the Denial Coder Prevention Associate is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient patient setting or discharge to an alternative level of care.

Duties and responsibilities

  • Responsible for providing timely referral/appeal determination by accurate
  • Usage of the Milliman Care Guidelines and or Interqual
  • Appropriate letter language to author appeal letter
  • Identification of referrals to the medical director for review
  • Appropriate selection of preferred and contracted providers
  • Proper identification of eligibility and healthcare plans
  • Maintaining compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards
  • Works directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals
  • Maintains and keeps in total confidence, all files, documents and records
  • Meets or exceeds production and quality metrics
  • Attend all mandatory meetings and trainings
  • Review, interpret and verify evaluation and management (E&M) and procedural codes according to the physician's documented office visit notes, orders, hospital notes and other pertinent physician documentation loaded in the medical record.
  • Utilize coding expertise to accurately code diagnoses based on the physician's documented diagnosis.
  • Identify and code global services and/or appropriate concurrent services according to coding guidelines, and applies correct modifiers.
  • Where necessary, correct codes that have been assigned by physician practices to ensure data and codes are consistent with ICD-10 CM Official Guidelines, CPT, and CMS.
  • All other job related duties as it relates to job function as delegated by management

Job Requirements


  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. List below is representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to preform the essential functions
  • Knowledge of CMS, State Regulations, URAC and NCQA preferred
  • ICD10 and CPT coding a plus
  • Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.
  • Minimum Experience: 3 to 5 years
  • Requires one of the following coding certifications: Certified Professional Coder (CPC),Certified Coding Specialist Physician (CCSP), Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Associate (CCA) through American Health Information Management Certification