DRG Appeals Specialist (RN)
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:
CorroHealth is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. CorroHealth has expanded its product offering to include DRG Revenue Integrity services. CorroHealth provides programmatic solutions for DRG compliance and revenue integrity by leveraging advanced analytics and DRG auditing and clinical expertise. CorroHealth 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!
This is a remote position
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.
Job Description:
TheDRG Appeals Specialistperformsreviewsof inpatient DRG payer denials on behalf of ourhospitalclient partners.Responsibilitiesinclude reviewingdenial letters,determinationanddata entry of audit recommendations,andresponsibility for professional and effective appeal responsesthat aresubmittedtimelyunderpayertimeframes.
Job Responsibilities:
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Performscomprehensive reviews ofinpatientmedicalrecordstovalidatethe MS/APR DRGs assigned for Medicare, Commercial,and Third-Party paidclaims.
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Validates that all ICD-10-CM/PCS, discharge disposition codes,andHospital Acquired Condition (HAC),Present on Admission (POA) indicatorsimpactingpaymentare documented, clinically supported,and assignedfollowingOfficial Coding Guidelines, compliant querypracticesandcurrent clinical validation criteria.
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Utilizes audit reference toolsandapplications (e.g., proprietary denials management application,TruCode,and3M encoder and grouper softwareandreferences).
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Reviews denial lettersrationale and formulatescustom appealresponselettersutilizingstrong critical thinking skills toindependentlyaccess cases for strengths and weaknesseswithin the appeals spectrum.Constructs and documents abriefand fact-basedcaseutilizingcompelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine,and official coding guidelines.Applies strong writing and grammar skills to formulate professional appeal lettersthatclearlysupport each appeal argument.
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Accurately abstracts denial audit findings into our proprietary applicationin accordance withstandard procedures.
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Maintains subject matter expertise in clinical validationcriteria and practices,ICD-10-CM/PCScode sets, coding guidelines, clinical documentation integrity,andinpatient payment methodologies.
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Attends continuing education workshops, webinars, etc., for coding anddocumentationintegrity and compliance.
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Other responsibilities as assigned. Duties may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing.
RequiredEducation/Experience