RN DRG Appeals Specialist

Job Summary

Working remotely in a full-time capacity, the RN DRG Appeals Specialist will perform comprehensive reviews of inpatient DRG payer denials, including the validation of medical records and the formulation of appeal responses based on clinical evidence and coding guidelines.

Key responsibilities:

• Conduct thorough reviews of inpatient medical records to confirm assigned MS/APR DRGs for various claims
• Formulate and submit custom appeal response letters based on denial letters and clinical evidence
• Maintain expertise in clinical validation criteria, coding guidelines, and inpatient payment methodologies

Required qualifications:

• Active RN/RHIA/RHIT license required; CCS certification must be obtained within one year of employment
• A minimum of 5 years of experience in inpatient coding quality assurance, DRG validation, or clinical documentation integrity
• CDIP or CCDS certification is highly preferred
• Proficiency in ICD-10-CM/PCS coding and understanding of MS/APR DRG payment methodologies
• Strong critical thinking and writing skills for crafting compelling appeal letters