DRG Appeals Nurse

Purpose

The Clinical Appeals Review Nurse reviews and analyzes denied/downgraded MS‑DRG and APR‑DRG and APC accounts received from all types of payers (e.g., Medicare, Commercial, and Third Party). Utilizing clinical and coding expertise, the Nurse will render determination on whether the denied/downgraded account is appealable based on the standards of each client. After review of the denial and medical record, the Clinical Appeals Review Nurse will provide either a reasoned explanation why no appeal can be written, or a detailed appeal letter based on current coding and regulatory guidelines and clinical criteria.

In either case the Nurse will then track and trend MRI defined denial root causes for each specific denial.

Manager of Clinical Appeals

• Perform efficient analysis of denied claims, pinpointing reason for denial and potential for success of appeal, including correct allocation of diagnostic and procedural codes under ICD‑10 Official Coding Guidelines, ICD‑10 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 Assistant.
• When the decision is made to appeal: write a clear, concise, grammatically correct appeals letter in MRI format and to MRI quality standards; be aware of the level of appeal and write according to the level; utilize current applicable clinical, legal, and coding standards; understand and strictly comply with time deadlines, writing appeals efficiently and timely; provide a reasoned root‑cause analysis and summary review for all clients within MRI standard;
  
  observe all HIPAA standards; obtain and maintain client computer accesses; participate in preparation of clear audit reports as needed; stay current in clinical, coding, and appeal‑writing areas and comply with MRI quality recommendations to maintain efficient and effective processes; identify coding and clinical documentation issues and provide proactive recommendations through the manager to clients; identify problematic accounts and seek review or return to client through the manager as appropriate;
  
  update patient account records to identify actions taken; liaise with third‑party payers and agencies regarding appeals to ensure optimal reimbursement and resolve billing issues, contract misrepresentations, and payment discrepancies.

• Registered Nurse (RN) License is required.
• CCS, CPC, CCDS, or RHIT Certification is required.
• Graduate of an accredited college or university; BSN is preferred.
• 5+ years of clinical experience in hospital inpatient and outpatient departments.
• 2+ years of clinical appeals/denials writing experience.
• Experience reviewing and analyzing denied/downgraded MS‑DRG and APR‑DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party).
• Experience in a variety of EMR systems (e.g., 3M, Nuance, Epic, etc.).
• Ideal candidate will possess the following:
  • Excellent verbal and written communication skills.
  • Excellent computer skills (Word, Excel, Skype, dual screens, etc.).
  • Excellent organizational and time‑management skills with a strong focus on detail and the ability to work remotely in an environment where HIPAA regulations can be enforced.
  • 2+ years of medical coding experience for inpatient and outpatient.
  • 2+ years of Clinical Documentation Improvement (CDI) experience.