Clinical Denial Specialist – Diagnosis Related Grouping (DRG)

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Responsible for all administrative activities surrounding management, timely review/appeal, reporting, monitoring, and analyzing hospital based clinical, coding, and diagnosis related grouping denials. This role ensures the accuracy and integrity of billed services by conducting comprehensive reviews of patient medical records, validating clinical relevance, assessing DRG accuracy, and identifying discrepancies between documentation and billed charges. The specialist prepares and submits detailed clinical appeals, negotiates with external auditors, and applies regulatory knowledge—including CMS guidelines, coding rules, and clinical standards—to support the organization’s position. The DRG Clinical Denial Specialist collaborates with clinical, coding, revenue cycle, and educational stakeholders to support ongoing process improvement, develop educational materials, and enhance organizational compliance and documentation quality. The coordinator is expected to work independently with minimal supervision while maintaining current clinical and coding knowledge and representing the organization effectively in communications with payers and external auditors.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate degree in healthcare administration, Nursing, Health Information Management, or related field AND Five (5) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle’

OR

Bachelor’s degree in healthcare administration, Nursing, Health Information Management, or related field AND Three (3) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle

2. Certification or License in one of the following:

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Registered Health Information Technician (RHIT) through the American Health Information Management Association (AHIMA)
• Registered Health Information Administrator (RHIA) through the American Health Information Management Association (AHIMA)
• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialist (ACDIS)
• Certified Documentation Integrity Practitioner (CDIP)through the American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS)through the American Health Information Management Association (AHIMA)
• Certified Inpatient Coder (CIC) through the American Academy of Professional Coders (AAPC)

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Two (2) years of hospital appeals/denials, HIM or compliance experience

2. Seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle setting.

3. Strong technology skills including but not limited to Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Manage the timely review of and response to enterprise hospital billing audits received electronically and via postal mail.

2. Collaborates with all CRC educators for educational content, opportunities and trends.

3. Initiates and facilitates feedback loop for all stakeholders as appropriate.

4. Completes clinical appeal writing for insurance denials.

5. Evaluates each patient medical record reviewing specific documents and clinical relevance, relating to patient treatment, applying UHDDS guidelines, procedure relevancy, DRG accuracy, complications and comorbid structure.

6. Identifying services billed versus services documented as rendered and clinically relevant.

7. Identifies acceptable versus unacceptable supportive information, based on CMS/ Coding Rules and Guidelines/Clinical Practice Standards.

8. Calculates the dollar total amounts for each discrepancy and submits necessary documents for adjustments, tracking and trending.

9. Negotiates with external auditors regarding billing issues as needed to reach agreement on disputed items; provides appropriate supportive documentation for questioned charges.

10. Completes and submits audit documentation in a timely fashion and legible manner. Completes work independently with minimum supervision.

11. Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for clinical documentation clarifying what is found in the medical record as appropriate.

12. Maintains current clinical and coding knowledge through reading, attendance at seminars, coding clinics, webinars, internal and external mandatory and informal education sessions.

13. Provides timely information regarding bill defense problems to manager, and offers recommendations to eliminate the unnecessary loss of revenue

14. Participates in departmental projects and educational opportunities to enhance effectiveness of the audit unit.  Coordinates and presents education to various groups within the hospital directed at identified problems

15. Develops appropriate learning tools and objectives for presentations.  Shares knowledge with others in a clear, concise and timely manner.

16. Responsible for all administrative activities with regard to denial management including: Collects all denial correspondence, updates the denial database regularly to accurately reflect all denials received, coordinates appeals process with all stakeholders.

17. Aggressively appeals denials with payers to obtain maximum recovery of revenues.

18. Attends all denial related meetings, as appropriate, to stay up to date on current organizational activities with regard to denials.

19. Applies regulatory knowledge regarding payer policies, CMS guidelines, coding conventions and hierarchical rules.

20. Provides support and assistance to Revenue Cycle Leadership as directed.

21. Directs all referrals for further appeal to outside agencies based on department guidelines.

22. Provides process improvement initiatives through route cause analysis.

23. Works cooperatively with enterprise Compliance, HIM/ROI, and other departments as needed to ensure timely response.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard Work Environment.

SKILLS AND ABILITIES:

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

538 SYSTEM HIM CDI