Clinical Denial Specialist – Diagnosis Related Grouping (DRG)

🔥 6 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Manage timely review and responses to enterprise hospital billing audits received electronically and by mail • Write and submit clinical appeals for insurance denials • Review patient medical records for clinical relevance, procedure relevance, DRG accuracy, complications, and comorbidities using UHDDS guidelines • Identify discrepancies between billed and documented services and calculate discrepancy amounts • Evaluate supporting information using CMS, coding, and clinical practice standards • Negotiate disputed billing issues with external auditors and provide supporting documentation • Maintain denial correspondence and update the denial database • Coordinate appeals with stakeholders and aggressively appeal denials to maximize revenue recovery • Collaborate with clinical, coding, revenue cycle, compliance, HIM/ROI, and educational stakeholders • Develop educational materials, presentations, learning tools, and process-improvement initiatives • Apply payer policies, CMS guidelines, coding conventions, and hierarchical rules • Provide denial-management information and recommendations to leadership • Work independently with minimal supervision and maintain current clinical and coding knowledge

🎯 Requirements

• 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 a related field and three (3) years of such experience • Current RN or LPN license, including qualifying multi-state eNLC license, OR RHIT, RHIA, CCDS, CDIP, CCS, or CIC certification • Preferred: two (2) years of hospital appeals/denials, HIM, or compliance experience • Preferred: seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle • Preferred: strong technology skills, including Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers