Denial RN DRG Appeal Writer1 / HIM Coding

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Position Summary :

The Denial Specialist is responsible for reviewing, analyzing and appealing denials related to DRG (Diagnostic Related Group) downgrades. This role involves validating the coding and clinical accuracy, ensuring proper documentation and collaborating with other departments to address payer concerns. Key responsibilities include timely investigation of DRG downgrades, submitting appeals, coordinating follow-up actions and ensuring compliance with regulatory standards. The specialist also plays a critical role in preventing future downgrades by identifying trends and providing feedback to improve coding and clinical documentation practices.

Position Responsibilities :

Key Areas of Responsibility

Denial Resolution

• Conduct a thorough review of medical records, coding and clinical documentation to validate or appeal payer denials.
• Prepare, document and submit appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory requirements.
• Work closely with the Clinical Documentation Improvement (CDI) and Coding teams to ensure accurate DRG assignment and enhance documentation practices that support appropriate reimbursement.
• Ensure that all DRG denial and appeal activities comply with federal, state, and payer-specific regulations, including maintaining knowledge of ICD-10-CM / PCS coding guidelines and CMS regulations.
• Maintain accurate records of denial appeals in the designated software, including the status of appeals, timelines, and outcomes.
• Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windows.
• Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgrades.
• Meet departmental performance goals, including Key Performance Indicators (KPIs) related to denial turnaround times, appeal success rates, and denial reduction targets.

Denials Prevention

Education

Stays current on payer policies, regulatory changes, coding guidelines (e.g., ICD-10, DRG), and healthcare regulations that could impact denials and coding practices.

Communication

Other

Working Relationships :

This Job Reports To : Medical Director

Qualifications :

Requirements and Specifications :

Education

Experience

Licensure, Certification, Registration

Language Skills

Knowledge, Skills and Ability Requirements

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