DRG Appeals Nurse; 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.

The DRG Appeals Specialist performs reviews of inpatient DRG payer denials on behalf of our hospital client partners. Responsibilities include reviewing denial letters, determination and data entry of audit recommendations, and responsibility for professional and effective appeal responses that are submitted timely under payer time frames.

Current and valid RN license DRG validation experience Medical necessity experience and appeal letter writing Coding certification (AHIMA or AAPC) is a plus This position requires up to 50% travel seeking to cover northern region (Chicago/Northern Indiana) seeking to cover central region (Indianapolis)

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.

Corro Health is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. Corro Health has expanded its product offering to include DRG Revenue Integrity services. Corro Health provides programmatic solutions for DRG compliance and revenue integrity by leveraging advanced analytics and DRG auditing and clinical expertise. Corro Health offers outstanding growth opportunities, a competitive salary and flexible work environments.

Corro Health has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Responsibilities:

Performs comprehensive reviews of inpatient medical records to validate the MS/APR DRGs assigned for Medicare, Commercial, and Third-Party paid claims. Validates that all ICD-10-CM/PCS, discharge disposition codes, and Hospital Acquired Condition (HAC), Present on Admission (POA) indicators impacting payment are documented, clinically supported, and assigned following Official Coding Guidelines, compliant query practices and current clinical validation criteria. Utilizes audit reference tools and applications (e.g., proprietary denials management application, Tru Code, and 3M encoder and grouper software and references).

Reviews denial letters rationale and formulates custom appeal response letters utilizing strong critical thinking skills to independently access cases for strengths and weaknesses within the appeals spectrum. Constructs and documents a brief and fact-based case utilizing compelling 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 letters that clearly support each appeal argument.

Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures. Maintains subject matter expertise in clinical validation criteria and…