DRG Appeals Specialist

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

This is a remote position within the US only.

Location: Remote within the US only

Schedule: Full-time, Monday - Friday

JOB SUMMARY:

As a DRG Downgrade Appeals Clinician, (DRG downgrade experience is mandatory) you will have the unique opportunity to evaluate hospitalizations across the country while utilizing your medical knowledge and gaining experience as an expert advisor. You will perform retrospective clinical case reviews and draft appeals that focus on establishing the Medical Necessity of diagnosis in question by the payor or 3rd party audit firm. 

We are seeking a highly skilled and dedicated Clinical RN Specialist to join our healthcare team. The ideal candidate will possess an active Registered Nurse (RN) license and extensive experience in Diagnosis-Related Group (DRG) downgrades (MANDATORY), with a strong background in various clinical settings. This role involves providing expert guidance on patient care, medical documentation, and hospital protocols to optimize patient outcomes and ensure compliance with healthcare regulations. The Clinical RN Specialist will serve as a vital resource for clinical education, process improvement, and interdisciplinary collaboration within our organization.

Essential Duties and Responsibilities:

• Performs retrospective medical necessity reviews to determine appeal eligibility of clinical validation DRG Downgrade denials.
• Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.
• Pertinent clinical facts include, but are not limited to, documenting that the clinical criteria utilized in diagnosing the patient was appropriate.
• Adheres to all coding and clinical documentation guidelines as endorsed by ACDIS and AHIMA.
• Collaborate with medical staff, case managers, and billing teams to facilitate appropriate patient classification and reimbursement processes.
• Provide targeted training and education to clinical staff on DRG requirements, medical terminology, anatomy, physiology, and documentation standards.
• Assist in developing and implementing policies that enhance clinical workflows, compliance with HIPAA regulations, and medical record accuracy.
• Monitor ongoing patient care activities to ensure adherence to best practices in acute care, ICU protocols, pediatrics, nursing home standards, and home care procedures.
• Support quality improvement initiatives by analyzing clinical data related to patient care outcomes and DRG performance metrics.
• Maintain up-to-date knowledge of healthcare regulations, medical terminology, anatomy, physiology, and industry best practices to serve as a subject matter expert.

Minimum Qualifications & Competencies:

• RN or MD degree with strong clinical knowledge - Active unrestricted clinical license in at least one state within the United States.
• DRG downgrade experience is mandatory.
• Certified in coding through either the AAPC (CPC/COC) or AHIMA (CCS/CCS-P) - Preferred
• Minimum of 5 years recent acute-care hospital experience, preferred.
• Minimum of 2 years Utilization Review / Case Management experience within the last 5 years.
• Must have excellent written communication skills and be computer proficient.
• Nursing background including hospital experience, nursing home care, teaching hospital exposure, pediatrics, or home health settings.
• Strong understanding of medical documentation processes, coding practices, and medical records management.
• Excellent knowledge of medical terminology, anatomy, physiology, and patient care procedures across diverse clinical disciplines.
• Demonstrated ability to train and develop healthcare staff through adult education techniques and instructional design.
• Familiarity with HIPAA compliance standards and confidentiality protocols in handling sensitive patient information.
• Effective communication skills for interdisciplinary collaboration and delivering clear educational content. Join our team as a Clinical RN Specialist to leverage your expertise in DRG downgrades while advancing clinical excellence through education and process optimization.

What we offer:

• Competitive hourly salary
• Medical/Dental/Vision Insurance
• Equipment provided
• 401k program
• Accrued PTO
• Paid Paternity & Maternity leave programs
• 9 paid annual holidays
• Life Insurance
• Long term disability
• Short term disability options
• Tuition reimbursement
• and much more!

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.