Company Overview
Theoria Medical is a comprehensive medical group and technology company dedicated to serving patients across the care continuum with an emphasis on post-acute care and primary care. Theoria serves facilities across the United States with a multitude of services to improve the quality of care delivered, refine facility processes, and enhance critical relationships. We offer a broad scope of services including multispecialty physician services, telemedicine, remote patient monitoring, and more. We currently operate primary care clinics and provide medical services to skilled nursing facilities in numerous states across the nation.
As a leading edge, innovative, and quality driven physician group, we continue to expand nationally. In pursuit of this, we continue to seek talented individuals to join our amazing team and care for our population. We wish to extend a warm welcome to all candidates interested in making a difference in healthcare delivery by joining the Theoria team
Theoria’s Finance Department is seeking an individual to join its team as a Coding and Denial Specialist. The Coding and Denial Specialist will be responsible for reviewing and resolving coding errors and other claim denials. The Coding and Denial Specialist will be responsible for various medical billing and coding tasks, as well as reviewing medical records to ensure accurate and compliant coding to resolve claim denials.
The candidate must have experience in healthcare revenue cycle management, strong leadership and communication skills, and a commitment to maximizing revenue while minimizing operational costs.
Essential Duties & Responsibilities
- Medical Coding Denial Resolution
- Review claims denied for diagnosis coding, procedure coding, and medical necessity issues.
- Research ICD-10, CPT, and HCPCS coding discrepancies contributing to claim denials.
- Identify incorrect, missing, or unsupported diagnosis codes.
- Review diagnosis-to-procedure relationships and payer-specific coding requirements.
- Research modifier, place-of-service (POS), and procedure code issues.
- Identify diagnosis sequencing and medical necessity-related denial trends.
- Coordinate with providers or compliance staff when documentation clarification or coding corrections are needed.
- Submit corrected claims and follow through until resolution.
- General Insurance Claim Denial Management
- Investigate and resolve a variety of professional claim denials, including:
- Authorization and referral denials.
- Bundling and incidental procedure denials.
- Non-covered service denials.
- Determine the appropriate resolution, including corrected claims, reconsiderations, appeals, or payer follow-up.
- Contact insurance companies to research claim status, obtain denial explanations, and identify resolution requirements.
- Work with payer representatives to resolve claim processing issues.
- Nursing Home & Long-Term Care Billing Knowledge
- Develop an understanding of professional billing requirements for providers rendering services in nursing homes and other long-term care settings.
- Review place-of-service requirements, including POS 31, 32, and 13, as applicable.
- Understand professional billing versus facility billing distinctions.
- Research payer-specific billing guidelines for services rendered in skilled nursing facilities, nursing homes, and assisted living facilities.
- Identify issues involving patient status, coverage limitations, Medicare, Medicare Advantage, Medicaid, and commercial insurance.
- Understand applicable Medicare Part B professional billing requirements for services rendered in institutional settings.
- Appeals & Corrected Claims
- Prepare and submit corrected claims, reconsiderations, and appeals in conjugation with third party vendor, eClinical Works
- Gather supporting documentation and coding references when necessary.
- Track appeal submission deadlines and payer response timelines.
- Maintain detailed records of denial research and resolution activities.
- Follow up on outstanding denials through final adjudication and payment.
- Denial Reporting & Root Cause Analysis
- Identify recurring denial patterns and communicate findings to management.
- Track denial categories, resolution status, and outstanding balances.
- Assist with denial trend reporting and performance metrics.
- Identify opportunities to prevent repeat denials through process improvements.
- Work collaboratively with billing, credentialing, provider enrollment, and clinical teams to address root causes.
Essential Functions and Responsibilities
- Be proficient in revenue cycle coding operations, including but not limited to billing, coding, claim denials and accounts receivable management.
- Analyze trends impacting charges, coding, collection, and accounts receivable and take appropriate action to realign staff, third party vendors and revise policies and procedures.
- Analyze billing and claims for accuracy and completeness; follow up with RCM teams and third party vendors on work queues, pending claims and unpaid AR.
- Spearhead the resolution of rejected or underpaid claims by conducting targeted appeals.
- Work with credentialing, billing and compliance staff to ensure compliance with regulatory requirements, including HIPAA and other federal and state regulations.
- Work closely with the RCM Directors, Compliance, Quality and Coding Teams to resolve documentation, coding and billing issues.
- Work closely with the Software Engineering team to ensure accurate coding options in the Electronic Health Record system.
- Develop and maintain strong relationships with RCM Directors, HR, Clinical Operations and Credentialing departments to ensure a smooth revenue cycle operation.
- Review and respond to various payor correspondence
- Communicate with patients, coworkers, and clients
Qualifications & Experience
- 5+ years of experience in medical billing, coding, insurance claims, or denial management.
- Strong knowledge of ICD-10-CM, CPT, and HCPCS coding.
- Understanding of professional medical claims (CMS-1500/837P).
- Familiarity with Medicare, Medicare Advantage, Medicaid, and commercial insurance billing.
- Experience researching and resolving insurance claim denials.
- Understanding of insurance payer policies and reimbursement guidelines.
- Familiarity with place-of-service codes and professional billing requirements.
- Experience navigating insurance payer portals and contacting insurance representatives.
- Strong research, analytical, and problem-solving skills.
- Ability to manage multiple outstanding claims and meet timely filing and appeal deadlines.
- Proficiency with Microsoft Excel and electronic billing/claims management systems.
Preferred Qualifications
- CPC, CCA, or equivalent coding certification required.
- Experience with professional provider billing in nursing homes, SNFs, assisted living, or long-term care environments.
- Experience with Medicare Part B billing.
- Familiarity with clearinghouses such as Waystar, Availity, or similar platforms.
- Experience with denial management reporting and RCM workflows.
- Advanced knowledge of the healthcare industry and a strong financial background
- Clear understanding of billing and collection regulatory guidelines and requirements
- Vast CPT, ICD-10, modifiers and payer policy expertise
- Vast knowledge in medical coding and medical record review
- Proficient background in reimbursements
- Strong analytical skills and attention to detail
- Excellent communication and interpersonal skills
- Ability to work in a fast-paced environment and manage multiple projects simultaneously
- Agility, strong leadership, problem-solving skills
- Ability to maintain up-to-date knowledge of technology and software including but not limited to Monday, Slack, Google suite of Applications, spreadsheets (Excel), Zoom, MS Teams, eClinicalWorks
Physical Requirements
- Must be punctual or on time and adhere to the company's Time and Attendance policy.
- Must be able to remain sitting for the majority of their shift.
Compensation and Benefits
- Competitive Compensation
- 401k with Employer Match
- Health, Dental, and Vision Insurance
- PTO and Holiday Pay
- Employer Paid Life insurance Policy
- Short and Long-Term Disability Insurance
- Company Provided Equipment
- Employee Assistance Program (EAP)
Employee must be able to perform the essential functions of this position satisfactorily, with or without a reasonable accommodation. Employer retains the right to change or assign other duties to this position.
