Medical Coding Auditor

Location Detail: 9 Farm Springs Rd Farmington (10566)

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The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization.
With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system.

Position Summary:

The level 2 Denial Specialist Appeal Writer reviews and analyzes Diagnostic Related Grouper (DRG) downgrades, preparing detailed, evidence-based appeal letters to defend assigned DRGs and optimize reimbursement. This role requires interpreting medical records, applying official coding guidelines, reviewing payer contracts and exercising clinical judgment. The specialist also helps prevent future downgrades by identifying trends and providing feedback to enhance coding accuracy and clinical documentation.

Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.

Key Areas of Responsibility

• Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.
• Review payer DRG downgrade denials to assess validity and potential for appeal.
• Analyze medical records, coding and clinical documentation to support the billed DRG using ICD-10-CM/PCS guidelines, UHDDS definitions, Coding Clinic, and regulatory requirements.
• Prepare and submit persuasive appeal letters that include a patient summary, evidence-based criteria, coding references and citations from authoritative sources.
• Maintain accurate appeal records in designated systems, track statuses and meet payer-specific submission deadlines.
• Lead trend analysis to identify denial patterns and recommend process improvements.
• Achieve departmental KPIs related to turnaround times, appeal success rates and denial reduction targets.

Education

• Provide ongoing education to HHC Institute leaders, providers, coding and CDI teams on DRG validation, documentation best practices, payer guidelines and best practices to minimize future denials.
• Collaborates with CDI provider leads at each facility to enhance denial proof documentation.
• Stay current with payer policies, regulatory changes, coding guidelines and industry best practices to support revenue protection efforts.

Communication

• Collaborate with Coding, CDI and physicians to clarify documentation and ensure accurate DRG assignment.
• Serve as primary contact with payers for DRG-related denials, clearly communicating clinical and coding rationale.
• Provide timely updates and feedback to leadership and departments on denial prevention efforts and appeal outcomes.

Other

• Performs other related duties as required.
• Mentors new and existing team members.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.

Working Relationships:

This Job

Reports To:

Medical Director

Requirements and Specifications:

Education

Minimum:
Bachelor of Science in Nursing

• Preferred:
  Master’s degree or equivalent

Experience

• Minimum:
  Four (4) years of progressive on-the-job inpatient and/or clinical documentation experience within healthcare revenue cycle or other healthcare field.
• Preferred:
  Six (6) years of progressive on-the-job experience with DRG denial management and appeals preferred.

Licensure, Certification, Registration

• Active Registered Nurse license from the State of Connecticut
• Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP)

Language Skills

• Strong written and verbal communication skills.

Knowledge, Skills and Ability Requirements:

• Strong knowledge of ICD-10-CM/PCS coding, DRG assignment and MS-DRG/APR-DRG systems.
• Excellent written communication skills, with the ability to translate complex clinical and coding concepts into persuasive…