Medical Coding Dispute Specialist

The Medical Coding Dispute Specialist is responsible for reviewing provider disputes and appeals for all lines of business at Network Health. This role requires advanced claims knowledge, medical coding experience, knowledge about provider reimbursement and a solid understanding of business operations.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha will be required occasionally for the position, including on first day.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

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Job Responsibilities:

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Develops detailed summaries and written responses for appeals, ensuring all findings are captured and trend information is included when requested.
• Produces clear, regulation-compliant communications for appeals, disputes, and grievances, presenting information accurately and succinctly.
• Analyzes claims workflows, contractual terms, reimbursement schedules, and system setups to pinpoint the underlying causes of payment discrepancies.
• Maintains current knowledge of payor reimbursement policies.
• Identifies coding and documentation issues and brings to the attention of the department manager
• Maintain an understanding and apply knowledge of National Correct Coding Initiatives (NCCI), Local Coverage Documents and National Coverage Documents (LCD/NCD) directives
• Maintain an understanding and apply knowledge of Medically Unlikely Edits (MUEs), and applicable regulatory requirements as well as payer guidelines to select appropriate codes and modifiers.
• Be able to review health care claims of intermediate to high complexity.
• Be able to identify overpayments or underpayments on claims.
• Ensures that desk level procedure (DLP) documents are kept current.
• Research and respond to coding questions from internal and external clients.
• Actively participates in shared accountability and commitment for departmental and organization-wide results.
• Prioritize workload to ensure deadlines are met weekly.
• Help with training associates as needed.
• Other duties as assigned.

Job Requirements:

• Associates degree or equivalent work experience required
• Medical Coding Credential from AAPC or AHIMA
• 3 or more years of experience working in health care or health insurance required
• 2 or more years of experience with provider disputes and claims processing required

Network Health is an Equal Opportunity Employer