Clinical Appeals-DRG Auditor

Purpose

The DRG Auditor – Clinical Appeals is responsible for conducting comprehensive retrospective reviews of inpatient claims to ensure accurate DRG assignment, appropriate reimbursement, and compliance with CMS guidelines and payer policies. This position plays a critical role in validating medical necessity, principal diagnosis selection, and CC/MCC coding accuracy to mitigate financial risk and support sound medical management decisions. Working on behalf of payer or provider clients, the auditor leverages deep clinical and coding expertise to identify improper payments, ensure documentation integrity, and align with federal and industry standards.

Clinical Appeals & CDI Manager

• Provide clinical input on provider appeals and grievances related to DRG assignment downgrades/denials.
• Perform other duties relevant to the position.
• Perform analysis of denied claims and craft appeal letter as needed or assigned, identifying reason for denial and potential success of appeal including correct allocation of diagnostic and procedural codes under official ICD-10 Coding and Procedural Coding Guidelines, 3M APR-DRG Classification System, CPT, HCPCS, Revenue Code, and all associated authorities such as CMS regulations, statutes, and AHA Coding Clinics and CPT Assistance.
• Conduct comprehensive medical record reviews to validate principal, secondary, and procedure code assignments.
• Evaluate Present on Admission (POA) indicators and their impact on DRG assignment.
• Assess medical necessity, admission appropriateness, and length of stay for inpatient encounters.
• Identify potential issues related to upcoding, unbundling, or inappropriate DRG assignments.
• Analyze DRG grouping logic and validate MS-DRG assignments using grouper software.
• Review physician documentation for accuracy and adequacy in support of reported diagnoses and procedures.
• Escalate complex clinical determinations to physician advisors when necessary.
• Ensure compliance with Medicare Severity DRG (MS-DRG), All Patients Refined DRG (APR-DRG) methodologies, and CMS guidelines.
• Prepare detailed audit findings, including clinical rationale and applicable regulatory references.
• Document deficiencies in provider documentation or code assignment and recommend corrective actions.
• Support clinical appeals and grievances by providing input on DRG-related downgrades and denials.
• Analyze denied claims, determine root causes, and draft appeal letters as needed or assigned, identifying reason for denial and potential success of appeal including correct allocation of diagnostic and procedural codes under official ICD-10 Coding and Procedural Coding Guidelines, 3M APR-DRG Classification System, CPT, HCPCS, Revenue Code, and all associated authorities such as CMS regulations, statutes, and AHA Coding Clinics and CPT Assistance.
• Stay current on applicable coding standards, CMS regulations, and payer policies.
• Other duties as assigned.

• Bachelor’s degree in Nursing, Health Information Management, Business, or a related field from an accredited institution.
• 5+ years of inpatient/acute hospital coding, DRG auditing, or medical record review experience.
• Certified coder: CCS, CCS-P, RHIA, RHIT, or CCDS (required).
• Proficient understanding of anatomy, physiology, medical terminology, and diagnostic procedures.
• Strong knowledge of CMS regulations, Medicare coverage policies, IPPS, and DRG methodology.
• Proven ability to interpret complex clinical documentation and apply coding guidelines accurately.
• Strong analytical skills with the ability to synthesize clinical and coding data.
• Excellent written and verbal communication skills; ability to present findings to both clinical and non‑clinical stakeholders.
• Highly organized and detail‑oriented with strong time management capabilities.

• Registered Nurse (RN) and/or Certified Clinical Documentation Specialist (CDIP or CCDS).
• 2+ years of experience in clinical appeals and denials writing.
• Familiarity with 3M APR-DRG, CPT, HCPCS, and Revenue Codes.
• Previous experience with payer‑side DRG auditing or revenue cycle roles.
• Working knowledge of managed care contracts and reimbursement guidelines.