DRG Clinical Appeals Specialist

DRG Clinical Appeals Specialist

Job Details - Full Time

Job Description:

The DRG Clinical Appeals Specialist performs reviews of inpatient DRG payer denials on behalf of our hospital clients. Responsibilities include reviewing denial letters, determination and data entry of audit recommendations, and responsibility for professional and effective appeal responses that are submitted timely under payer deadlines.

Job Responsibilities:

  • Performs comprehensive reviews of inpatient medical records to validate the MS/APR DRGs assigned for Medicare, Medicaid and Commercial claims.
  • Validates that all ICD-10-CM/PCS, discharge disposition codes, and Hospital Acquired Condition (HAC), Present on Admission (POA) indicators impacting payment are documented, clinically supported based on current clinical validation criteria, and assigned following Official Coding Guidelines.
  • Utilizes audit reference tools and applications (e.g., proprietary denials management tracking file, TruCode and references).
  • Reviews denial letters rationale and formulates custom appeal response letters utilizing strong critical thinking skills to independently assess cases. Constructs a fact-based appeal utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine, and official coding guidelines. Applies strong writing and grammar skills to formulate professional appeal letters that clearly support each appeal argument. 
  • Constructs an educational review results letter for the client when the appeal was justified.
  • Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures.
  • Maintains subject matter expertise in clinical validation criteria and practices, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies.
  • Attends continuing education workshops, webinars, etc., for coding and documentation integrity and compliance.
  • Completes inpatient record reviews for accuracy of coding, adequacy of documentation to support optimal DRG assignment as well as appropriate credit for risk adjustment.  These duties are assigned as time allows, based on the volume of denial work.
  • Other responsibilities as assigned. Duties may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing.

Skills:

  • Extensive Inpatient Coding Skills. Possess regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS/APR DRG payment methodologies, including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
  • Clinical Validation Skills. Demonstrate the ability to identify, apply, and validate the use of current industry standard clinical indicators, risk factors and treatment protocols used in clinical validation of payment impacting code assignment. Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, disease assessment, management and treatment is required.
  • Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes, and evaluates information as a guide to validate audit results.
  • Adaptability. Maintains effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures.
  • Initiative. Is proactive and self-directed. Shows initiative and responsibility in taking the necessary steps towards problem resolution. Is self-sufficient and does not need to rely on others to complete a job.
  • Performance. Meets or exceeds both production and quality expectations while performing complex medical record audits. Able to execute under pressure of time constraints and while managing multiple responsibilities.
  • Planning and Organization. Proactively prioritizes initiatives, effectively manages resources and can multi-task. Actively manages their work assignments and seeks additional tasks when appropriate.
  • Communication Skills. Communicates clearly, proactively, and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise rationales in support of findings and successfully crafts appeal letters with precise logic.
  • Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail, identifies inaccurate code assignment, mines medical records for all relevant and supporting evidence, intuitively understands appeal strategies and conscientiously follows all steps in the audit and appeals process. Committed to life-long learning.
  • PC Skills. Demonstrates proficiency in Microsoft Office and Teams, and navigating various EHRs.

Benefits

  • Enjoy work-life balance with a predictable schedule
  • Compensation includes salary plus bonus opportunities
  • Medical, Dental, Vision, Life Insurance coverage, 401K
  • Holidays, paid time off
  • Reimbursement for continuing education and association dues

Experience:

  • Inpatient coding and clinical documentation improvement:  5 years
  • Denials management experience (Preferred)

License/Certification:

  • Certified Coding Specialist (Preferred)
  • RHIA or RHIT (Preferred)
  • CDIP or CCDS (Preferred)

Work Location: Remote

Please submit resumes to croberts@acsteam.net.