DRG and Clinical Appeals Specialist

Key Responsibilities 

This position is designed as a cross-functional revenue integrity role. While primary responsibilities focus on clinical and DRG appeals, the specialist is expected to support DRG validation audits, coding compliance reviews, clinical validation initiatives, and denial-prevention activities during periods of lower appeals volume. Flexibility and the ability to work across multiple revenue cycle disciplines are essential requirements of the position. 

Key Responsibilities 

• Review denied claims involving DRG downgrades, clinical validation and coding denials. 

• Conduct a comprehensive analysis of 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-level 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. 

• Maintain productivity during fluctuations in denial volume by independently conducting DRG audits, coding compliance reviews, clinical validation assessments, pre-bill revenue integrity reviews, and denial-prevention initiatives to support organizational revenue cycle objectives 

Qualifications 

Education and Experience 

• Current RN license or professional coding credential required. 

• Bachelor’s degree in nursing, Health Information Management, or a related healthcare field preferred. 

• Minimum of five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations. 

• Minimum of three years of experience writing successful payer appeals preferred. 

• Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials. 

• Demonstrated experience working with electronic health record (EHR) systems and encoder applications. 

• Proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI or coding technologies preferred. 

• One or more of the following certifications preferred: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC. 

Knowledge, Skills, and Abilities 

• 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, with 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 and  

• Demonstrated ability to function effectively in a flexible, cross-trained role, transitioning between denials and appeals activities, DRG validation, coding compliance auditing, clinical validation reviews, and other revenue integrity functions based on business needs 

Key Competencies 

• Clinical Expertise: Interprets clinical indicators, treatment patterns, and disease processes to support diagnosis validation. 

• Appeals Writing: Develops well-supported, evidence-based arguments designed to maximize overturn success rates. 

• Analytical Thinking: Identifies weaknesses in denial rationales and opportunities for reimbursement recovery. 

• Collaboration and Flexibilty: Partners effectively with physicians, CDI teams, coding professionals, and revenue cycle stakeholders. 

• Regulatory Knowledge: Applies CMS regulations, coding guidance, and payer policies accurately and consistently. 

• Results Orientation: Focuses on maximizing recovered revenue and reducing recurring denial patterns. 

Job Benefits 

• Health insurance 

• Vision insurance 

• Dental insurance 

• Life insurance 

• Retirement plan 

• Paid time off 

Location 

Remote 

Compensation Range 

$95,000–$135,000