Appeals and Denials Specialist

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

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