The specialist analyzes medical records, claims data, and coding to appeal insurance provider MS-DRG and coding changes, ensuring the most accurate ICD-10-CM/PCS codes support rendered services. Duties include conducting retrospective reviews, developing appeal arguments, and identifying documentation issues for staff education.
Requirements summary
Candidates must possess an RHIA, RHIT, and/or CCS certification with knowledge of ICD-9-CM/ICD-10-CM/PCS coding and MS-DRG assignment, requiring a minimum of 5 years of inpatient coding experience in an acute care, teaching hospital setting. Required knowledge includes anatomy, pathophysiology, medical terminology, and extensive understanding of federal and payer-specific reimbursement regulations.
professional certificateData EntryProcedure CodingClaims Data AnalysisReimbursement KnowledgeClinical Documentation ImprovementDiagnosis CodingICD-10-CM/PCSPhysician QueryingMedical Record AnalysisRetrospective ReviewEPIC UtilizationUHDDS GuidelinesMS-DRG AccuracyAppeal Argument Development3M Encoder UtilizationAdministrative Law Judge Hearings Participation
Job description
St.
Luke's is proud of the skills, experience and compassion of its employees.
The employees of St.
Luke's are our most valuable asset!
Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors.
Assures that the most accurate and descriptive codes from the AHA ICD-9-CM/ICD-10-CM/PCS diagnoses and/or procedures support the services/treatment rendered.
JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement.
Work with the physician liaison in review of patient medical records identified by RAC/MIC/CGI/QIO and other outside auditors in retrospective reviews for DRG and coding-related issues.
May participate in review of other medical necessity issues as needed.
Develop and apply appeal arguments to defend the coding of and by the coding professionals and be able to refute the coding determination made by the outside payor including but not limited to CMS, Aetna, IBC, Omniclaim, QIP, Gateway Health, etc.
Draft appeal letters, including the coding argument, to support network coding.
Identify clinical documentation improvement issues and through excellent communication with physicians, nurses, coding and other members of the health care team and work independently to resolve such issues.
Participate as needed in Administrative Law Judge (ALJ) hearings.
Spends approximately 20% of their time weekly coding/abstracting patient medical records according to ICD-10-CM/PCS, UHDDS and CMS guidelines.
Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes, and MS-DRG assignment.
Performs data entry of coded patient medical records into EPIC, maintaining a 95% coding accuracy rate as measured through quality reviews.
Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment.
PHYSICAL/SENSORY DEMANDS: Sitting, standing and light lifting.
Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information.
Corrected vision and hearing to within normal range.
Hearing as it relates to normal conversation.
Works inside with adequate lighting, comfortable temperature and ventilation.
EDUCATION: RHIA, RHIT and/or CCS with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment.
Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required.
TRAINING, KNOWLEDGE AND EXPERIENCE: Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting.
Knowledge of anatomy and physiology, pathophysiology, and medical terminology required.
Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred.
Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity.
Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.
Please complete your application using your full legal name and current home address.
Be sure to include employment history for the past seven (7) years, including your present employer.
Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable.
It is highly recommended that you create a profile at the conclusion of submitting your first application.
Thank you for your interest in St.
Luke's!!
St.
Luke's University Health Network is an Equal Opportunity Employer.
Founded in 1872, St.
Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites.
With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey.
St.
Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St.
Luke’s Children’s Hospital.
SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction.
It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital.
The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY.
In 2021, St.
Luke’s was identified as one of the 15 Top Health Systems nationally.
St.
Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row.
Also, for the third straight year, St.
Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award.
In 2025, St.
Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024.
Lastly, in 2025, St.
Luke’s was named a Top Workplace in New Jersey for the third year in a row.
