DRG and Clinical Appeals Specialist

Second Wave Delivery Systems•Las Vegas, NV

11h•$95,000 - $135,000•Remote

About The Position

This is a cross-functional revenue integrity role primarily focused on clinical and DRG appeals. The specialist also supports DRG validation audits, coding compliance reviews, clinical validation initiatives, and denial-prevention activities when appeals volume is lower. The position requires flexibility and the ability to work across multiple revenue cycle disciplines. The specialist reviews denied claims, analyzes medical records and coded data, prepares evidence-based appeals, and validates coding accuracy and reimbursement determinations. The role also tracks appeal outcomes and denial trends, contributes to client education, and conducts other revenue integrity reviews as needed to support organizational revenue cycle objectives.

Requirements

Current RN license or professional coding credential.
At least five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations.
Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials.
Demonstrated experience working with electronic health record (EHR) systems and encoder applications.
Advanced knowledge of ICD-10-CM/PCS coding guidelines, MS-DRG and APR-DRG methodologies, and reimbursement systems.
Strong understanding of clinical documentation integrity principles and clinical validation standards.
Exceptional analytical and critical-thinking skills, including the ability to interpret complex clinical records.
Excellent written communication skills, including the ability to develop concise, persuasive, and technically sound appeal letters.
Knowledge of CMS regulations, payer audit methodologies, Coding Clinic guidance, and industry best practices.
Ability to prioritize workload independently.
Ability to function effectively in a flexible, cross-trained role and transition between revenue integrity functions based on business needs.

Nice To Haves

Bachelor’s degree in nursing, Health Information Management, or a related healthcare field.
At least three years of experience writing successful payer appeals.
Proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI or coding technologies.
One or more of the following certifications: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC.

Responsibilities

Review denied claims involving DRG downgrades, clinical validation, and coding denials.
Analyze medical records, coded data, physician documentation, laboratory results, imaging findings, treatments, and patient outcomes to identify appeal opportunities.
Draft clear, persuasive, evidence-based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.
Prepare first- and second-level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.
Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, acute kidney injury, malnutrition, encephalopathy, and other MCC/CC conditions, using evidence-based practice and literature.
Validate coding accuracy, DRG assignment, principal diagnosis selection, present-on-admission indicators, and reimbursement determinations.
Research and incorporate peer-reviewed clinical literature, specialty society guidance, and regulatory references to support appeal positions.
Track appeal outcomes, recovered revenue, overturn rates, and denial trends for reporting and continuous improvement.
Participate in client education initiatives focused on denial prevention, documentation improvement, and coding accuracy.
Conduct DRG audits, coding compliance reviews, clinical validation assessments, pre-bill revenue integrity reviews, and denial-prevention initiatives when needed to maintain productivity and support organizational revenue cycle objectives.
Transition between denials and appeals activities, DRG validation, coding compliance auditing, clinical validation reviews, and other revenue integrity functions based on business needs.