DRG and Clinical Appeals Specialist at Second Wave Delivery Systems. Location Information: USA Only. . 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.
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