RN DRG Appeals Specialist

Job Summary

To support hospital client partners, the full-time remote RN DRG Appeals Specialist will perform reviews of inpatient DRG payer denials, including analyzing denial letters, formulating appeal responses, and ensuring compliance with coding guidelines.

Key responsibilities:

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

Required qualifications:

• Active RN license in good standing
• Minimum of 5 years of experience in inpatient coding quality assurance, DRG validation, or clinical documentation integrity
• Experience in medical necessity and appeal letter writing
• DRG validation experience is essential; coding certification (AHIMA or AAPC) is a plus
• CDIP or CCDS certification is highly preferred