Clinical Denial Specialist – Diagnosis Related Grouping

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee timely evaluation and response to enterprise hospital billing audits.

• Draft and submit clinical appeals for insurance claim denials.

• Examine patient medical records for clinical relevance, thorough documentation, procedure appropriateness, DRG accuracy, complications, and comorbidities.

• Detect inconsistencies between billed services and documented services.

• Utilize CMS guidelines, coding regulations, clinical standards, payer policies, and hierarchical rules.

• Compute discrepancy amounts and submit documentation for adjustments while monitoring and analyzing results.

• Negotiate contested billing matters with external auditors and supply necessary documentation.

• Liaise with clinical and administrative staff to gather clarifying documentation.

• Keep abreast of current clinical and coding knowledge through ongoing education and professional development.

• Report billing defense issues and suggest strategies to mitigate revenue loss.

• Create and deliver educational materials and learning resources.

• Oversee denial correspondence, databases, and the appeals process.

• Challenge payer denials to optimize revenue recovery.

• Participate in denial-related meetings and direct referrals for further appeals to external agencies.

• Conduct root cause analysis and implement process improvement initiatives.

• Collaborate with Compliance, HIM/ROI, Revenue Cycle Leadership, educators, and additional departments.

⛳️ Requirements

• Associate degree in healthcare administration, Nursing, Health Information Management, or a related field, along with five (5) years of experience in hospital billing, acute care settings, CDI, inpatient coding, or revenue cycle; OR a bachelor's degree in a related field with three (3) years of such experience.

• Current certification/license as a Registered Nurse, Licensed Practical Nurse, RHIT, RHIA, CCDS, CDIP, CCS, or CIC.

• Preferred: two (2) years of experience in hospital appeals/denials, HIM, or compliance.

• Preferred: seven (7) years of experience in hospital billing, acute care settings, CDI, inpatient coding, or revenue cycle.

• Preferred technology skills include Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers.

🏝️ Benefits

• Comprehensive health insurance plans.

• Generous paid time off and holidays.

• Opportunities for professional development and continuing education.

• Retirement savings plan with employer matching.