Clinical Denial Specialist – Diagnosis Related Grouping (DRG)

🕒 June 16

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

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

• Responsible for all administrative activities surrounding management, timely review/appeal, reporting, monitoring, and analyzing hospital based clinical, coding, and diagnosis related grouping denials. • 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. • 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. • Collaborates with clinical, coding, revenue cycle, and educational stakeholders to support ongoing process improvement, develop educational materials, and enhance organizational compliance and documentation quality. • 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.

🎯 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 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 • 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)

🏖️ Benefits

• Health insurance • 401(k) matching • Paid time off • Flexible work arrangements • Professional development opportunities