Medical Coding Appeals Analyst
Core
Ensures accurate adjudication of claims by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.
Role type
Medical Coding Appeals Analyst
Builds
Enterprise reimbursement policy, system edits, and fee schedule updates
Domain
Healthcare insurance / Medical coding
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical record documentation review, CPT/HCPCS code analysis, ICD-10 coding, CMS policy interpretation, clinical research, data analysis, legislative mandate identification, claims system auditing, pre-adjudication claims review, provider correspondence, staff training
Preferred skills
CEMC, RHIT, CCS, CCS-P certifications
Technologies
Claims systems, CMS systems
Responsibilities
Review medical record documentation for Evaluation and Management, CPT, HCPCS, and ICD-10 codes; Translate medical policies into reimbursement rules; Perform CPT/HCPCS code and fee schedule updates; Coordinate research and respond to system inquiries and appeals; Conduct research of claims systems to identify adjudication issues; Perform pre-adjudication claims reviews; Prepare correspondence to providers regarding coding updates; Train customer service staff on system issues
Seniority
Individual Contributor, 2+ years experience