Appeals and Denials Specialist

Job Type

Full-time

Description

The Appeals and Denials Specialist is responsible for triaging and writing DRG downgrades and clinical validation appeal letters for multiple clients. The Appeals and Denials Specialist will ensure appropriate action is taken within appeal deadlines. This position collaborates with the Appeals and Denials team and other departments as needed.

PRIMARY JOB RESPONSIBILITIES:

Performs review of the medical record including documentation, reports, flowsheets, and test results, applying evidence-based criteria related to DRG and clinical validation denials

Creates appeal letters utilizing the relevant information from the medical record; supported by current clinical standards and facility guidelines, evidence-based medicine, professionally recognized standards of health care, and ICD-10-CM/PCS Official Coding Guidelines

Is flexible, able to navigate multiple EHRs and other databases used by Accuity or the client, performs reviews, and submits letters of appeal per the client specific workflows

Able to prioritize cases to meet appeal deadlines

Detail-oriented

Collaborates with Accuity Physician and Accuity CDI in appropriately identified clinical denials requiring communication to the Accuity clinical review teams

Maintains clinical expertise and trends in healthcare, reimbursement methodologies and specialty areas by participating in professional organizations, seminars, and educational programs

Performs miscellaneous job-related duties as assigned Requirements

POSITION QUALIFICATIONS:

Education:

Associate or bachelor's degree in nursing or licensure in other clinical healthcare field such as MD, NP, PA.

Experience:

Minimum 3 years of CDI experience

or experience with clinical inpatient DRG Downgrades and clinical denials

Licensure and/or Credentials:

At least one of the following: MD, RN, BSN, CCDS, CDIP

Knowledge, Skills, and Abilities:

Inpatient clinical experience

Extensive knowledge of revenue cycle management and coding services

Requires good interpersonal and customer service skills

Demonstrated knowledge of ICD-10-CM, ICD-10-PCS

Motivated and self-directed

Experience with electronic health records and health information systems

Organized and able to prioritize to ensure objectives are met in a timely manner

Ability to establish and maintain cooperative working relationships with physicians and staff

Ability to use a PC in a Windows environment, including MS Word, Excel and PPT

Independent, focused individual able to work remotely