DRG Denial Specialist

Job Description

Job Description

Description:

The DRG Denial Specialist is responsible for reviewing DRG-related payer denials and authoring appeal letters when an appeal is supported by the clinical documentation and coding guidelines. Using expert-level knowledge of ICD-10-CM/PCS, MS-DRG/APR-DRG classification systems, and Official Coding Guidelines, the DRG Denial Specialist evaluates the medical record against the original coding and the payer's stated rationale to determine whether the DRG assignment should be defended or revised. The DRG Denial Specialist works under the oversight of a Physician Advisor and collaborates closely with the broader Appeal Service Line to ensure appeals are accurate, well-supported by coding guidance, and submitted within payer deadlines. 

DRG Appeal Functions 

• Review clinical validation and coding-related DRG denials  
• Evaluate the medical record against the original coding, coding guidelines, clinical validation standards, and Coding Clinic guidance to determine if an appeal is warranted 
• Author clear, well-supported DRG appeal letters that defend or clarify the DRG assignment based on clinical documentation and coding guidelines 
• Escalate cases involving clinical validation questions or physician-level clinical judgment to a Physician Advisor 
• Collaborate with Physician Advisors and expert coders on complex cases requiring combined coding and clinical expertise 
• Manage assigned DRG denial review work queues to ensure timely turnaround within payer deadlines 

Coding & Quality Functions 

• Maintain current knowledge of evidence-based standards for clinical validation of commonly denied diagnoses as well as AHA Coding Clinic guidance and ICD-10-CM/PCS code changes 
• Track and trend DRG denial reasons and outcomes to identify patterns and opportunities for improvement 
• Provide input and recommendations to Brundage Group leadership for process improvement and template refinement 
• Maintain accurate and organized documentation of all denial reviews and appeal outcomes 

Client & Operational Support 

• Work collaboratively with operations, client engagement, and clinical account executives to ensure cases are received and processed in a timely manner to meet payer deadlines 
• Maintain IT access to client sites 
• Maintains HIPAA compliance 
• Other duties as assigned.
• Strong coding knowledge, including ICD-10-CM/PCS and MS-DRG/APR-DRG classification systems 
• Expert-level knowledge of evidence-based standard for clinical validation of commonly denied diagnoses  
• Strong critical thinking skills and meticulous attention to detail  
• Demonstrated ability to author clear, well-organized, and persuasive DRG appeal letters 
• Strong understanding of Official Coding Guidelines and Coding Clinic guidance 
• Excellent written and verbal communication skills 
• Strong interpersonal skills and ability to build relationships with key team members 
• Ability to work independently and manage a caseload against payer deadlines 
• Strong computer skills and working knowledge of EMRs 
• At least 3 years of recent inpatient coding, CDI or denial management experience  
• Prior experience authoring DRG appeal letters required 
• Experience with multiple Electronic Health Records preferred 

Preferred Qualifications: 

• Credentials: a combination of any of the following: CCS, CDIP, CCDS, RHIT, RHIA, CPC

• Conditions typically associated with an office environment. While performing the essential duties and responsibilities, the employee is regularly required to talk or hear. May be frequently required to sit, stand or walk. Moderate to prolonged reading, typing, and computer work. Ability to perform tasks involving physical activity that may include lifting up to 25 pounds. Subject to exposure to all environmental hazards associated with healthcare and office work.