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About the role
Headquarters: Las Vegas, Nevada, United States
URL: https://www.secondwaveds.com/
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
To apply: https://weworkremotely.com/remote-jobs/second-wave-delivery-systems-drg-and-clinical-appeals-specialist
