Denial RN DRG Appeal Writer1 / HIM Coding

Hartford HealthCare•Farmington, CT

29d

About The Position

The Denial Specialist is responsible for reviewing, analyzing and appealing denials related to DRG (Diagnostic Related Group) downgrades. This role involves validating the coding and clinical accuracy, ensuring proper documentation and collaborating with other departments to address payer concerns. Key responsibilities include timely investigation of DRG downgrades, submitting appeals, coordinating follow-up actions and ensuring compliance with regulatory standards. The specialist also plays a critical role in preventing future downgrades by identifying trends and providing feedback to improve coding and clinical documentation practices.

Requirements

Associate of Science in Nursing
Two (2) years of progressive on-the-job inpatient and/or clinical documentation experience within healthcare revenue cycle or other healthcare field.
Active Registered Nurse license from the State of Connecticut
Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP)
Strong written and verbal communication skills.
Strong understanding of ICD-10-CM/PCS coding, DRG assignment, and payer regulations related to DRG validation.
Ability to analyze medical records, coding documentation, and payer denial reasons to determine appropriate appeal strategies.
Excellent written and verbal communication skills, with the ability to clearly articulate clinical and coding justifications in appeal letters.
Ability to manage multiple denials, prioritize tasks, and ensure timely submission of appeals.
Experience with electronic health record (EHR) systems, coding software, and denial tracking tools.
Proficient in tracking systems and data management tools.
Strong organizational skills with a high level of accuracy and attention to detail.
Strong interpersonal skills.
Excellent communication and collaboration abilities.
Strong problem-solving, analytical, and critical thinking skills.
Experience working with cross-functional departments to research and resolve issues using innovative solutions.
Ability to work independently.
Ability to provide outstanding customer service.

Nice To Haves

Bachelor of Science in Nursing
Three (3) years of progressive on-the-job experience with DRG denial management and appeals preferred.

Responsibilities

Conduct a thorough review of medical records, coding and clinical documentation to validate or appeal payer denials.
Prepare, document and submit appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory requirements.
Work closely with the Clinical Documentation Improvement (CDI) and Coding teams to ensure accurate DRG assignment and enhance documentation practices that support appropriate reimbursement.
Ensure that all DRG denial and appeal activities comply with federal, state, and payer-specific regulations, including maintaining knowledge of ICD-10-CM/PCS coding guidelines and CMS regulations.
Maintain accurate records of denial appeals in the designated software, including the status of appeals, timelines, and outcomes.
Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windows.
Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgrades.
Meet departmental performance goals, including Key Performance Indicators (KPIs) related to denial turnaround times, appeal success rates, and denial reduction targets.
Analyze denial patterns to identify root causes and collaborate on preventive strategies.
Proactively address discrepancies between payer policies, regulatory standards and internal processes to prevent future denials.
Develop and implement process improvements aimed at preventing denials, such as better workflows, enhanced communication between departments, or technology solutions.
Provide regular reports and feedback to leadership and relevant departments on denial prevention efforts, identifying areas needing attention.
Provide ongoing education to the coding and CDI teams regarding DRG validation, payer guidelines, and best practices to minimize future denials.
Stays current on payer policies, regulatory changes, coding guidelines (e.g., ICD-10, DRG), and healthcare regulations that could impact denials and coding practices.
Collaborate with Revenue Cycle and Medical Staff teams to ensure a unified approach to denial management and appeals.
Serve as the primary contact with payers on DRG-related denials. Effectively communicate the clinical and coding rationale for the DRG assignment and challenge inappropriate denials.
Respond to department inquiries regarding claim denials, explaining the resolution process and providing updates as needed.
Communicates across departments as needed.
Performs other related duties as required.
Mentors new and existing team members.
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.