Analyst, Pre-Pay Dispute Coding

Provides support for provider denial coding dispute activities. Investigates and resolves disputes related to provider appeals and ensures that claims adhere to correct billing standards and regulations.

Essential Job Duties

• Reviews coding-related provider claims denials by systematically examining medical records, denial reasons, submitted claims, and claim history, in accordance with applicable state, federal, and Molina guidelines, rules, and protocols, to determine whether the documentation substantiates the services rendered.
• Conducts independent audits of non-medical records to verify billing accuracy; makes decisions within designated authority to either overturn or uphold denials in a timely manner.
• Generates and communicates determinations to the provider using appropriate letter language and provides necessary guideline links.
• Identifies, documents, and communicates coding errors or inconsistencies; collaborates with appropriate internal departments to capture and track issues, and ensure precise code editing and compliance.
• Completes data points within internal applications to comply with departmental auditing requirements.
• Participates in the enhancement of departmental processes to maintain alignment with current coding regulations and guidelines while refining internal procedures.