DRG Clinical Appeals Specialist

Position Type: Full-Time

Office Location: Remote, USA

Versalus Health is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. Versalus Health has expanded its product offering to include DRG Revenue Integrity services. By leveraging advanced analytics and DRG auditing and clinical expertise, Versalus Health provides programmatic solutions for DRG compliance and revenue integrity. Versalus offers outstanding growth opportunities, a competitive salary and benefits package including bonuses based on individual and company performance, and reimbursement for continuing education and association dues. Versalus has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Description:

The DRG Clinical Appeals Specialist performs inpatient MS-DRG and APR-DRG payer denial reviews on behalf of our client partners. This includes review of denial letters for Medicare, Commercial and Third-Party paid accounts, interpreting payer denial rationales, crafting custom appeal letters, data entry of audit recommendations, and timely turnaround on appeal letters. In addition, the DRG Clinical Appeals Specialist is responsible for identifying payer denial trends, assists in creating appeal rational templates, and communicating findings with management team.

 Job Responsibilities:

  • Performs inpatient medical record reviews to validate the MS/APR DRGs assigned for Medicare, Commercial and Third-Party paid accounts
  • Validates that all payment impacting ICD-10-CM/PCS, discharge disposition codes, & Hospital Acquired Condition (HAC) Present on Admission (POA) indicators are documented, clinically supported, and assigned in accordance with Official Coding Guidelines, compliant query practices & current clinical validation criteria
  • Utilizes audit reference tools & applications (e.g., proprietary denials management application, TruCode & 3M encoder, and grouper software & references.)
  • Accurately interprets insurance denial rationales and determines appropriate overturn strategies
  • Formulates custom appeal letters utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine, and official coding guidelines
  • Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures
  • Assists with management and client outcome reports
  • Maintains subject matter expertise in clinical validation, code sets, coding guidelines, clinical documentation integrity, & inpatient payment methodologies
  • Assists in training new team members as needed
  • Timely processing of denials to ensure on-time response delivery
  • Coordinates and problem solves denial issues in collaboration with DRG Appeals Support team
  • Attends continuing education workshops, webinars, etc., for coding and documentation integrity and compliance
  • Perform other duties as assigned.

Education & Certification:

  • RN with BS. – preferably with strong clinical background such as ICU or ED
  • Certification in Clinical Documentation Improvement (e.g., CDIP or CCDS) is required.
  • Certified Coding Specialist certification (CCS) is highly preferred and will be required after one year of employment. (Assistance with preparation is provided.)
  • Certifications and/or professional license must be maintained as a condition of employment.

Work Experience:

  • A minimum of 5 years of experience in any of the following roles:
  • Preparing appeals for clinical denials
  • Participation on inpatient denials management team
  • DRG validation
  • Inpatient coding quality assurance
  • Clinical Documentation Specialist (CDS), Educator, or Manager

Knowledge, Skills & Abilities

  • Expert Inpatient Coding Skill. Extensive regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS/APR DRG payment methodologies to include Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
  • Expert Clinical Validation Skills. Demonstrate ability to identify, apply and validate the use of current industry standard clinical indicators, risk factors and treatment protocols used in clinical validation of payment impacting code assignment. Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, & disease assessment, management & treatment.
  • Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes and evaluates information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to validate audit results and correct as necessary.
  • Adaptability. Maintaining effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures.
  • Initiative. Is proactive & self-directed in that they show initiative & responsibility in taking the necessary steps towards problem resolution.
  • Energy. Consistently maintains high levels of activity or productivity sustained over long working hours when necessary; operates with vigor, effectiveness, and determination.
  • Stress Tolerance. Maintains stable performance under pressure of time constraints & while managing multiple responsibilities.
  • Planning and Organization. Proactively prioritizes initiatives, effectively manages resources with keen ability to multi-task. Actively manages their work assignments and seeks additional tasks when appropriate.
  • Meets or exceeds both production & quality expectations while performing complex medical record audits.
  • Communication Skills. Communicates clearly, proactively and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise rationales in support of findings and successfully crafts appeal letters with precise logic.
  • Work Independently. Is self-sufficient and does not need to rely on others to complete a job.
  • Quality Orientation. Pays meticulous attention to detail, identifies aberrant code assignment, mines medical records for all relevant and supporting evidence, intuitively understands appeal strategies & conscientiously follows all steps in the audit and appeals process.
  • Curious Nature. Actively seek out new ideas, possibilities & answers to the tough questions.
  • PC Skills. Demonstrates proficiency in Microsoft Office & Teams, Skype, WebEx, VPN access, navigating a variety of EHRs, and ability to problem solve Internet connectivity issues.

Physical Requirements:

May be expected to sit at a desk for long hours. Repetitive movement of hands and fingers – typing and/or writing. Occasional standing, walking, stooping, kneeling or crouching. Ability to reach with hands and arms, talk and hear.

Versalus Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law.

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