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Novus Group

Retrospective Appeals Coder - REMOTE


Clinical Data Management



5 years


Pittsburgh, Pennsylvania, United States

Pay rate up to $37.00 per hour ($77,000 annually) based on experience
  • Full-time, Direct Hire position
  • 100 % fully remote
  • Work Schedule: Monday through Friday – Eastern Time Zone standard daylight business hours
Novus Group is your advocate to access DIRECT HIRE positions with a multibillion-dollar health enterprise that has over 100,000 employees, hospitals, corporate offices, a multi-million-member health insurance division and much, much more! Ranked consistently within the top hospitals in America, the Company is known nationally, internationally, and globally. The Company offers many high value benefits: Competitive Pay, Outstanding Benefits (healthcare, vision, dental, life insurance, paid parental leave, generous PTO and paid holiday time, tuition assistance, help with work/life balance with options for child/pet care, help with elderly loved ones, and many more employee support programs to help you succeed in all aspects of your work and personal life!!

We seek a Retrospective Appeals Coder possessing the following skills, experience and/or certification(s):

MINIMUM Qualifications:
  • Bachelor's degree in Business Administration or related field or Registered Record Administrator (RAA) is preferred.
  • Clinical Document Specialist/Clinical validation of coding experience is preferred
  • 5 years Coding Experience REQUIRED.
  • Extensive knowledge of DRG/APC, ICD-9/10, CPT/HCPCS classifications and coding of diagnosis and procedures is REQUIRED.
  • Knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is REQUIRED.
  • Prior appeal/grievance experience preferred.
Certification Required: Candidate must currently possess a valid certification in one or more of the following areas:
  • Certified Coding Specialist (CCS) OR, Registered Health Information Administrator (RHIA), OR Registered Health Information Technician (RHIT)
The Retrospective Appeals Coder provides support to the local coding departments by initiating the retrospective appeal process for coding denials. Drawing on a coding knowledge base and knowledge of payor regulations, the Retrospective Appeal Coder is responsible for assessing the presence of criteria to recover denied reimbursement through appeal.

  • Assist in determining system-wide coding needs through investigation of retrospective denials and identification of root cause. Review and resolve pre-bill edits as needed
  • Maintain current knowledge of regulatory guidelines related to retrospective appeals.
  • Serve as a liaison between coding and payors and facilitates payor/physician contact when indicated.
  • Maintain collaborative relationships with coding management and appeal departments at payor organizations.
  • Collaborate with other departments to ensure all information to support retrospective appeal is identified.
  • Formulate written appeal letter as appropriate incorporating supportive documentation. (i.e., medical criteria, state regulations, etc.).
  • Perform coding review for cases referred for retrospective appeal/audits to determine if appeal is warranted.
  • Act as liaison to other departments relative to the retrospective appeal process.
  • Provide ongoing education to coding and other departments related to the appeal process.
  • Ensure the appeal process is followed to accomplish timely and appropriate appeals.
  • Identify and assign a root cause to each case to ensure denial reasons are tracked.
  • Monitor and evaluate areas of process improvement related to the retrospective appeal process.