DRG and Clinical Appeals Specialist

Key Responsibilities This position is designed as a cross-functional revenue integrity role. While primary responsibilities focus on clinical and DRG appeals, the specialist is expected to support DRG validation audits, coding compliance reviews, clinical validation initiatives, and denial-prevention activities during periods of lower appeals volume. Flexibility and the ability to work across multiple revenue cycle disciplines are essential requirements of the position. Key Responsibilities • Review denied claims involving DRG downgrades, clinical validation and coding denials. • Conduct a comprehensive analysis of medical records, coded data, physician documentation, laboratory results, imaging findings, treatments, and patient outcomes to identify appeal opportunities. • Draft clear, persuasive, evidence-based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations. • Prepare first-level and second-level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers. • Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, acute kidney injury, malnutrition, encephalopathy, and other MCC/CC conditions, using evidence-based practice and literature. • Validate coding accuracy, DRG assignment, principal diagnosis selection, present-on-admission indicators, and reimbursement determinations. • Research and incorporate peer-reviewed clinical literature, specialty society guidance, and regulatory references to support appeal positions. • Track appeal outcomes, recovered revenue, overturn rates, and denial trends for reporting and continuous improvement. • Participate in client education initiatives focused on denial prevention, documentation improvement, and coding accuracy. • Maintain productivity during fluctuations in denial volume by independently conducting DRG audits, coding compliance reviews, clinical validation assessments, pre-bill revenue integrity reviews, and denial-prevention initiatives to support organizational revenue cycle objectives Qualifications Education and Experience • Current RN license or professional coding credential required. • Bachelor’s degree in nursing, Health Information Management, or a related healthcare field preferred. • Minimum of five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations. • Minimum of three years of experience writing successful payer appeals preferred. • Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials. • Demonstrated experience working with electronic health record (EHR) systems and encoder applications. • Proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI or coding technologies preferred. • One or more of the following certifications preferred: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC. Knowledge, Skills, and Abilities • Advanced knowledge of ICD-10-CM/PCS coding guidelines, MS-DRG and APR-DRG methodologies, and reimbursement systems. • Strong understanding of clinical documentation integrity principles and clinical validation standards. • Exceptional analytical and critical-thinking skills, with the ability to interpret complex clinical records. • Excellent written communication skills, including the ability to develop concise, persuasive, and technically sound appeal letters. • Knowledge of CMS regulations, payer audit methodologies, Coding Clinic guidance, and industry best practices. • Ability to prioritize workload independently and • Demonstrated ability to function effectively in a flexible, cross-trained role, transitioning between denials and appeals activities, DRG validation, coding compliance auditing, clinical validation reviews, and other revenue integrity functions based on business needs Key Competencies • Clinical Expertise: Interprets clinical indicators, treatment patterns, and disease processes to support diagnosis validation. • Appeals Writing: Develops well-supported, evidence-based arguments designed to maximize overturn success rates. • Analytical Thinking: Identifies weaknesses in denial rationales and opportunities for reimbursement recovery. • Collaboration and Flexibilty: Partners effectively with physicians, CDI teams, coding professionals, and revenue cycle stakeholders. • Regulatory Knowledge: Applies CMS regulations, coding guidance, and payer policies accurately and consistently. • Results Orientation : Focuses on maximizing recovered revenue and reducing recurring denial patterns. Job Benefits • Health insurance • Vision insurance • Dental insurance • Life insurance • Retirement plan • Paid time off Location Remote Compensation Range $95,000–$135,000 To apply: https://weworkremotely.com/remote-jobs/second-wave-delivery-systems-drg-and-clinical-appeals-specialist