Clinical Denial Specialist – Diagnosis Related Grouping (DRG)

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

📋 Description

• Oversee prompt evaluation and responses to enterprise hospital billing audits received both electronically and by mail.

• Compose and submit clinical appeals for insurance denials.

• Examine patient medical records for clinical and procedural relevance, DRG accuracy, complications, and comorbidities, adhering to UHDDS guidelines.

• Detect discrepancies between billed services and documented services, calculating the amounts of these discrepancies.

• Assess supporting data in accordance with CMS, coding, and clinical practice standards.

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

• Maintain denial correspondence and update the denial tracking database.

• Coordinate appeals with relevant stakeholders and proactively appeal denials to optimize revenue recovery.

• Collaborate with clinical, coding, revenue cycle, compliance, HIM/ROI, and educational stakeholders.

• Create educational materials, presentations, learning tools, and process improvement initiatives.

• Implement payer policies, CMS guidelines, coding conventions, and hierarchical rules.

• Provide denial management insights and recommendations to leadership.

• Operate independently with minimal supervision while staying current with clinical and coding knowledge.

⛳️ Requirements

• Associate degree in healthcare administration, Nursing, Health Information Management, or a related field, combined 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.

• A current RN or LPN license, including a qualifying multi-state eNLC license, OR RHIT, RHIA, CCDS, CDIP, CCS, or CIC certification.

• 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: strong technological skills, including proficiency in Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers.

🏝️ Benefits

• Comprehensive healthcare benefits package.

• Opportunities for professional development and continuing education.

• Flexible work schedule options.

• A supportive work environment with a focus on teamwork.