DRG and Clinical Appeals Specialist

Our take on this role

About this role

Review denied claims and write evidence-based appeals for DRG downgrades, clinical validation and coding denials. Support audits and denial prevention during lower appeals volume; the role is remote.

What could you bring from clinical work?

• Nurses: Your experience reviewing medical records and clinical indicators to assess diagnoses could help with validating diagnoses and writing evidence-based payer appeals.

Full job description from Second Wave Delivery Systems

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