DRG Appeals Specialist

Key Responsibilities

• Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.
• Analyze payer denials involving:
  • DRG downgrades
  • Removal of CC/MCC
  • Clinical validation denials
  • Coding validation disputes
• Prepare clear, concise, and compliant DRG appeal letters supported by:
  • ICD-10-CM/PCS Official Guidelines
  • UHDDS reporting requirements
  • CMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)
• Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards.
• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases.
• Ensure timely filing of appeals in accordance with payer and client deadlines.
• Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time.
• Participate in quality audits, peer reviews, and continuous process improvement initiatives.
• Maintain strict compliance with HIPAA and data privacy regulations.

• Inpatient Coding Experience (required).
• Strong working knowledge of:
  • ICD-10-CM and ICD-10-PCS
  • MS-DRG and APR-DRG systems
  • CC/MCC logic and DRG impact
• Demonstrated experience handling DRG appeals or inpatient coding denials.
• Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.
• Excellent written communication skills with the ability to cite official coding and clinical references.
• High attention to detail, critical thinking, and strong analytical skills.
• Ability to work independently while meeting productivity and quality benchmarks.