Coding/Denial Analyst

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Research and analyze denials, patient complaints, and Coding Compliance software audit messages to optimize reimbursement for Sanford Health. Identify trends with reimbursement and coding. Provide information, feedback and direction on coding related software edits, denial issues, reimbursement trends and billing/coding errors to providers, Coding and Reimbursement staff, and the Business Office.

Reports to
As Assigned

Education, Experience and Skills Requirements
Must have extensive knowledge of diagnostic and procedural terminology, ICD-9, CPT-4 and HCPC coding schemes usually acquired through the following programs or certification: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Licensed Practical Nurse (LPN), Certified Professional Coder (CPC), Certified Professional Coder - Hospital (CPC-H), Certified Coding Specialist (CCS), or Certified Coding Specialist Professional (CCS-P). Must have two years experience in coding for professional charges. Must have at least two years experience with Medicare and other third party reimbursement. Must have a working knowledge of anatomy, physiology, and pathophysiology to understand disease processes, treatment or management of medical or surgical conditions. Must have current knowledge in coding schemes and prospective payment systems and clinical practices and technology. Must have computer skills and knowledge of information systems. Must be able to effectively train others to achieve maximum accuracy. Must have knowledge of state and federal laws, rules and regulations.

Licensure/Certification Requirement
Must maintain certification in RHIA, RHIT, LPN, CCS, CCS-P, CPC or CPC-H by fulfilling continuing education requirements. If the associate is not certified at hire, the associate must be certified within two years of the date of hire.

Job Specific Competencies
  • Demonstrates the ability to locate, research, comprehend and appropriately apply third party payer rules and regulations in completing billing and reimbursement projects on an ongoing basis.
  • Researches and analyzes complex coding related claim denials, payment challenges, and other associate's unresolved denials and discounts and employ resolutions that ensure accurate and optimal reimbursement for the health system.
  • Researches and analyzes audit messages generated by Pathways Compliance Advisor on codes previously assigned by Coding Specialists to ensure coding accuracy. Makes final decisions regarding modifier/diagnosis code/procedure code selection prior to claim submission. Analyzes the validity of audit messages generated by the software program to ensure the accuracy and quality of the product.
  • Provides timely analysis and resolution for Coding Related Patient Complaints and second opinions on unsettled complaints. Maintains a liaison with Patient Accounts staff to ensure good customer service and quality responses that patients can understand.
  • Demonstrates knowledge and skill in analyzing patient records to identify and assign accurate CPT, ICD-9-CM and HCPC codes.
  • Serves as a resource to providers, coding associates and other service areas (both local and regional) on coding questions and guidelines.
  • Provides feedback to Coding Specialists, Reimbursement staff, and clinical areas regarding trends in coding inaccuracy identified through denials, patient complaints and compliance edits.
  • Maintains liaison with Billing Compliance to ensure coding policies and procedures are accurate, up-to-date, and followed.
  • Effectively educates and trains coding and reimbursement staff how to properly address patient complaints, investigate denials and operate the Third Party Worklist.
  • Responsible for analyzing payor specific policies in regard to medical necessity and ABN requirements and subsequently creating and updating an internal Guideline that details the pertinent information in a user-friendly format for Sanford associates.

Core Competencies
Customer Service
  • Interacts with customers in a warm and friendly way.
  • Takes immediate action to meet customer requests or needs.
  • Listens to understand what customers have to say.
  • Recognizes safety hazards and takes corrective action; seeking assistance when needed.
  • Demonstrates knowledge of operational policies and procedures.
  • Performs work safely, without causing harm or risk to self, others or property.
System Behavior
  • Makes a decision considering the impact of the decision on other areas.
  • Initiates collaboration with others outside of service area.
  • Demonstrates personal commitment to the principles, values, and ethics of the organization.
  • Models accountability for learning by sharing knowledge and learning from others.
  • Builds effective working relationships.
  • Expresses appreciation to others for their work.
  • Treats others with respect.

Leadership Competencies
  • Demonstrates both knowledge and application of Sanford policies, procedures, and guidelines.
  • Demonstrates the ability to take charge, take unpopular stands if necessary, face difficult situations, and is looked to for direction from others.
  • Facilitates and supports change within the Sanford Health.
  • Demonstrates commitment to continuous learning for themselves and staff.
  • Demonstrates and applies continuous quality improvement knowledge and skills.

Information Management Competencies
  • Demonstrates skill in accessing, preparing and using information as relevant to position.
  • Verbalizes and demonstrates knowledge of procedures for maintaining security, confidentiality and integrity of employee, patient, family and other medical information.
  • Demonstrates ability to collect, analyze and present data as appropriate to position.

Equipment Competencies
  • Demonstrates skill in use of equipment relevant to position; verbalizes knowledge of appropriate safety procedures.
  • Diagnoses equipment problems; fixes or seeks out someone to fix.
  • Consistently informs appropriate person of problems encountered with repairs or calibration of equipment.

Blood Exposure
  • This position is classified as a Category III position under OSHA guidelines with no risk of exposure to bloodborne pathogens and other potentially infectious materials.


Physical Requirements:
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