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
Location
Remote
Compensation Range
$95,000-$135,000
