Location: Chicago, Illinois
Business Unit: Rush Medical Center
Hospital: Rush University Medical Center
Department: HB Commercial Billing-Collect
Work Type: Full Time (Total FTE between 0.9 and 1.0)
Shift: Shift 1Work Schedule: 8 Hr (8:00:00 AM - 4:30:00 PM)
Pay Range: $34.89 - $50.63 per hour
Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush's anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.
Summary:Join Rush University Medical Center and help protect the integrity of clinical documentation, coding accuracy, and reimbursement. As a Senior DRG Appeals Coding Analyst, you will review complex DRG downgrades, clinical validation denials, and payer audits, developing evidence-based appeals supported by ICD-10-CM/PCS guidelines, clinical documentation, and regulatory standards.
Working closely with Coding, Clinical Documentation Integrity (CDI), Compliance, and Revenue Cycle teams, you will analyze inpatient records, identify denial trends, and advocate for accurate reimbursement through expert coding and clinical analysis.
This is an exciting opportunity for a certified coding professional with strong inpatient coding, audit, and appeals experience who is passionate about making a measurable impact in a leading academic healthcare organization.
Responsibilities:- Review, analyze, and respond to DRG audits related to principal diagnosis, MCC/CC, severity of illness (SOI), procedures, and clinical validation denials to determine the validity of requested revisions, appeal eligibility, and appropriate appeal strategy.
- Write clear, concise, and evidence-based appeal letters that defend DRG assignments by effectively linking provider documentation, objective clinical indicators, treatments rendered, and resource utilization, using language tailored to payer specific criteria.
- Conduct comprehensive audits of inpatient medical records to validate original DRG assignments based on clinical documentation and applicable ICD-10-CM/PCS coding guidelines.
- Identify and evaluate clinical indicators supporting the originally assigned DRG, tertiary DRG, severity of illness (SOI), and associated resource utilization.
- Prepare appeals supported by authoritative references, including ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic guidance, CMS MS-DRG definitions and regulatory requirements, payer medical and reimbursement policies, clinical practice guidelines, and other authoritative medical reference sources.
- Clearly articulate severity of illness (SOI) criteria, with particular emphasis on payor-specific clinical validation requirements.
- Ensure all appeal submissions meet CMS, OIG, compliance, regulatory, and audit standards.
- Support internal and external audits by providing clear appeal rationale, clinical documentation, and authoritative reference citations.
- Maintain complete and accurate documentation of appeal activities, determinations, and supporting evidence within designated audit and tracking systems.
- Collaborate with Inpatient Coders and Coding Auditors for second-level reviews of coding quality, assisting with clinical validation query development or refinement, and identifying denial and downgrade risk trends.
- Partner with Clinical Documentation Integrity (CDI) specialists to request CDI review for clinical validation denials, identify documentation gaps affecting DRG defense, clarify clinical conditions, and recommend documentation improvement strategies to prevent future DRG downgrades.
- Work with Corporate Compliance and Enterprise Risk Management to identify, assess, and mitigate risks related to clinical validation denials, DRG downgrades, coding accuracy, documentation deficiencies, and policy non-compliance.
- Identify audit trends to support denial prevention initiatives through education, training, and feedback to coding, CDI, and operational teams.
Required Job Qualifications:- High School Diploma or GED
- AHIMA Coding certification required
- Three coding audit experience or five years of coding experience.
- Ability to interpret and analyze medical records, ancillary reports, and third-party payer guidelines.
- Proficiency in Microsoft Suite and Excel.
- Excellent verbal and written communication skills.
- Epic Experience
- Ability to communicate effectively with providers and hospital department leadership.
- Meets or exceeds standard/guidelines for productivity. Strives to meet and maintain production goals set by the management team.
