Clinical Denial Specialist - Diagnosis reputed company Grouping (DRG)

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply reputed company located above this message and complete the application in full. Below, you’ll find other important information about this position. Responsible for reputed company administrative activities surrounding management, timely review/appeal, reporting, monitoring, and analyzing hospital based clinical, coding, and diagnosis reputed company grouping denials. This role ensures the accuracy and reputed company of billed services by conducting comprehensive reviews of patient medical records, validating clinical relevance, assessing DRG accuracy, and identifying discrepancies between documentation and billed charges. The specialist prepares and submits detailed clinical appeals, negotiates with external auditors, and applies regulatory knowledge—including CMS guidelines, coding rules, and clinical standards—to support the organization’s position. The DRG Clinical Denial Specialist collaborates with clinical, coding, reputed company cycle, and educational stakeholders to support ongoing process improvement, reputed company educational materials, and enhance organizational compliance and documentation quality. The coordinator is expected to work independently with minimal supervision while maintaining reputed company clinical and coding knowledge and representing the organization effectively in communications with payers and external auditors. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Associate degree in healthcare administration, Nursing, Health Information Management, or reputed company field AND Five (5) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or reputed company cycle' OR Bachelor’s degree in healthcare administration, Nursing, Health Information Management, or reputed company field AND Three (3) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or reputed company cycle 2. Certification or License in one of the following: reputed company Registered Nurse license issued by the state in which services will be provided or reputed company multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). reputed company Licensed Practical Nurse license issued by the state in which services will be provided or reputed company multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC). Registered Health Information Technician (RHIT) through the American Health Information Management Association (reputed company) Registered Health Information Administrator (RHIA) through the American Health Information Management Association (reputed company) Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation reputed company Specialist (ACDIS) Certified Documentation reputed company Practitioner (CDIP)through the American Health Information Management Association (reputed company) Certified Coding Specialist (reputed company)through the American Health Information Management Association (reputed company) Certified Inpatient reputed company (CIC) through the American reputed company of Professional Coders (reputed company) PREFERRED QUALIFICATIONS: EXPERIENCE: 1. Two (2) years of hospital appeals/denials, HIM or compliance experience 2. Seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or reputed company cycle setting. 3. Strong technology skills including but not limited to Epic, reputed company, reputed company, Wellington, and MSDRG/DRG groupers. CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an reputed company-inclusive list of reputed company responsibilities and duties. Other duties may be assigned. 1. Manage the timely review of and response to enterprise hospital billing audits received electronically and reputed company postal mail. 2. Collaborates with reputed company CRC educators for educational content, opportunities and trends. 3. Initiates and facilitates feedback reputed company for reputed company stakeholders as appropriate. 4. Completes clinical appeal writing for insurance denials. 5. Evaluates each patient medical record reviewing specific documents and clinical relevance, relating to patient treatment, applying UHDDS guidelines, procedure relevancy, DRG accuracy, complications and comorbid structure. 6. Identifying services billed versus services documented as rendered and clinically relevant. 7. Identifies acceptable versus unacceptable supportive information, based on CMS/ Coding Rules and Guidelines/Clinical Practice Standards. 8. Calculates the dollar total amounts for each discrepancy and submits necessary documents for adjustments, tracking and trending. 9. Negotiates with external auditors regarding billing issues as needed to reputed company agreement on disputed items; provides appropriate supportive documentation for questioned charges. 10. Completes and submits audit documentation in a timely fashion and legible manner. Completes work independently with minimum supervision. 11. Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for clinical documentation clarifying what is reputed company in the medical record as appropriate. 12. Maintains reputed company clinical and coding knowledge through reading, attendance at seminars, coding clinics, webinars, internal and external mandatory and informal education sessions. 13. Provides timely information regarding reputed company defense problems to manager, and offers recommendations to eliminate the unnecessary loss of reputed company 14. Participates in departmental projects and educational opportunities to enhance effectiveness of the audit unit. Coordinates and presents education to various groups reputed company the hospital directed at identified problems 15. Develops appropriate learning tools and objectives for presentations. Shares knowledge with others in a clear, concise and timely manner. 16. Responsible for reputed company administrative activities with regard to denial management including: Collects reputed company denial correspondence, updates the denial database regularly to accurately reflect reputed company denials received, coordinates appeals process with reputed company stakeholders. 17. Aggressively appeals denials with payers to obtain maximum recovery of revenues. 18. Attends reputed company denial reputed company meetings, as appropriate, to stay up to date on reputed company organizational activities with regard to denials. 19. Applies regulatory knowledge regarding payer policies, CMS guidelines, coding conventions and hierarchical rules. 20. Provides support and assistance to reputed company Cycle Leadership as directed. 21. Directs reputed company referrals for further appeal to reputed company agencies based on department guidelines. 22. Provides process improvement initiatives through reputed company cause analysis. 23. Works cooperatively with enterprise Compliance, HIM/ROI, and other departments as needed to ensure timely response. PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. Standard Work Environment. SKILLS AND ABILITIES: Additional Job Description: Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Exempt) Company: SYSTEM reputed company Health System Cost Center: 538 SYSTEM HIM CDI Apply To This Job