DRG Appeals Nurse, RN

This is a fully remote position, open to applicants in Alabama, +38 more states.

📋 Description

• Conduct thorough reviews of inpatient medical records to confirm MS/APR DRGs for Medicare, Commercial, and Third-Party claims.

• Verify ICD-10-CM/PCS codes, discharge disposition codes, HACs, and POA indicators that influence payment.

• Ensure that documentation is clinically supported and adheres to Official Coding Guidelines, compliant query practices, and up-to-date clinical validation criteria.

• Utilize audit reference tools and applications, including proprietary denials management software, TruCode, and 3M encoder and grouper software.

• Analyze denial-letter rationales and create tailored appeal response letters.

• Independently evaluate appeal cases for their strengths and weaknesses.

• Develop and document evidence-based cases utilizing clinical evidence, industry clinical guidelines, evidence-based medicine, and official coding guidelines.

• Compose professional appeal letters that reinforce each appeal argument.

• Abstract denial audit findings into the proprietary application in accordance with standard procedures.

• Maintain expertise in clinical validation, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies.

• Participate in continuing education workshops and webinars.

• Achieve production and quality standards while conducting complex medical record audits.

• Perform additional assigned duties.

⛳️ Requirements

• Current and valid RN license in good standing.

• Professional RN license must be retained as a condition of employment.

• At least 5 years of experience in inpatient coding quality assurance, DRG validation, DRG appeal, or Clinical Documentation Integrity as a Clinical Documentation Specialist, Educator, or Manager.

• Experience in DRG validation.

• Familiarity with medical necessity and appeal letter writing.

• Advanced inpatient coding skills.

• Expertise in regulatory ICD-10-CM/PCS coding.

• Subject matter expertise in MS/APR DRG payment methodologies, including HACs, POA assignment, and discharge disposition codes.

• Proficiency in clinical validation, including up-to-date industry-standard clinical indicators, risk factors, and treatment protocols.

• Knowledge of anatomy, physiology, pathology, laboratory processes, imaging, pharmacology, disease assessment, management, and treatments.

• Strong critical thinking abilities.

• Exceptional written and verbal communication skills.

• Proficiency in Microsoft Office, Teams, WebEx, VPN access, various EHRs, and troubleshooting internet connectivity.

• Coding certification (AHIMA or AAPC) is advantageous.

• CCS is preferred after one year of employment.

• RHIT/RHIA/CPC credentials are a plus.

• CDIP or CCDS is highly preferred.

• Capability to work at a computer terminal for 6–8 hours daily.

• Ability to lift and move items weighing up to 20 lbs. infrequently.

🏝️ Benefits

• Competitive salary.

• Bonus opportunities.

• Medical, Dental, and Vision coverage.

• 401K plan.

• Paid holidays.

• Paid time off.

• Short-term and long-term disability insurance.

• Life insurance.

• Reimbursement for continuing education and association dues.

• Predictable work schedule.

• Flexible work environments.

• Opportunities for professional development and personal growth.