Clinical DRG Appeals Specialist

1 week ago

United States ARC Claims Management Full time

Job Summary

The Clinical DRG Appeals Specialist has an extensive background in facility-based nursing and/or inpatient coding and has a high level of understanding of reimbursement guidelines, specifically the MS-DRG and APR-DRG payment systems. This position is responsible for reviewing appeals for claims with DRG revisions and determining their outcomes. For upholding, the DRG Appeals Specialist will generate high-quality rebuttals with additional support for the initially identified changes. The Clinical DRG Appeals Specialist will review and lead client-required meetings (ex., JMAC Calls). Auditing inpatient medical records to validate assigned DRGs will be performed on an as-needed basis, requiring high-quality, recoverable claims rationales supporting any identified changes.

Key Responsibilities:

  • Review, analyze, and respond to DRG-related appeals to determine the validity of requested revisions.
  • Develop and write clear, evidence-based rebuttals to support upheld DRG determinations.
  • Effectively Utilizes Audit Tools. Utilizes DRG Claims Management AV2 system with a high level of proficiency to make audit/appeal determination and rebuttal.
  • Audit inpatient medical records, as needed, to validate DRG assignments and ensure compliance with official coding guidelines, UHDDS definitions, and payer policies.
  • Identify and document high-quality recoverable claim rationales for any validated DRG changes.
  • Stay current with changes in coding guidelines, DRG methodology, and payer audit trends.
  • Meets or Exceeds Standards/Guidelines for Productivity. Strives to hit and maintain production goals set by the management team. The goals will be set per complexity indicators.
  • Meets or Exceeds Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the clinical operations management team.

Requirements

  • Education-RN and Coding Certification (At least one of the following is required and is to be maintained as a condition of employment.) - CCS, CCS-P, CPC, RHIT, RHIA
  • 5+ years of working with ICD-10 CM, ICD-10 PCS MS-DRG, and APR-DRG with a broad knowledge of medical claims payment and reimbursement methodology and an extensive knowledge of coding and medical terminology.
  • 3+ years of auditing experience.
  • Adherence to Official Coding Guidelines, AHA Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge.
  • Proficient in Microsoft Office Suite.
  • Excellent written and verbal communication skills.

Work Environment

  • This is an at-home-based position.
  • This position requires a high-speed internet connection and a work environment free from distractions (all other equipment will be provided by the company).
  • This role aligns with specific productivity and quality goals.

Job Type: Full-time

Pay: From $90,000.00 per year

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Health insurance
  • Paid time off
  • Parental leave

Application Question(s):

  • Do you have Coding Certification through AHIMA or AAPC?
  • Do you have experience working DRG appeals for a vendor/third party?

Work Location: Remote

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