DRG and Clinical Appeals Specialist

Responsibilities: — Review denied claims involving DRG downgrades, clinical validation, and coding denials. — Analyze 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 clinical validity of diagnoses commonly targeted by payers 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 conducting DRG audits, coding compliance reviews, clinical validation assessments, pre-bill revenue integrity reviews, and denial-prevention initiatives. Requirements: — Current RN license or professional coding credential required. — Bachelor’s degree in nursing, Health Information Management, or related healthcare field preferred. — Minimum five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations. — Minimum three years of experience writing successful payer appeals preferred. — Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials. — Experience with electronic health record (EHR) systems and encoder applications. — Proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI or coding technologies preferred. — Preferred certifications include CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC. — 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. — Excellent written communication skills for developing persuasive appeal letters. — Knowledge of CMS regulations, payer audit methodologies, Coding Clinic guidance, and industry best practices. — Ability to prioritize workload independently and function effectively in a flexible, cross-trained role. Benefits: — Health insurance — Vision insurance — Dental insurance — Life insurance — Retirement plan — Paid time off Location: Remote Compensation Range: $95,000–$135,000 per year