Clinical Denial Specialist – Diagnosis Related Grouping

🔥 0 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 response to enterprise hospital billing audits • Write and submit clinical appeals for insurance denials • Review patient medical records for clinical relevance, documentation, procedure relevance, DRG accuracy, complications, and comorbidities • Identify discrepancies between billed and documented services • Apply CMS guidelines, coding rules, clinical standards, payer policies, and hierarchical rules • Calculate discrepancy amounts and submit adjustment documentation while tracking and trending results • Negotiate disputed billing issues with external auditors and provide supporting documentation • Communicate with clinical and administrative personnel to obtain clarifying documentation • Maintain current clinical and coding knowledge through education and professional development • Report bill-defense problems and recommend ways to reduce revenue loss • Develop and present educational materials and learning tools • Manage denial correspondence, databases, and the appeals process • Appeal payer denials to maximize revenue recovery • Attend denial-related meetings and direct referrals for further appeal to outside agencies • Provide root cause analysis and process improvement initiatives • Collaborate with Compliance, HIM/ROI, Revenue Cycle Leadership, educators, and other departments

🎯 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 Registered Nurse, Licensed Practical Nurse, RHIT, RHIA, CCDS, CDIP, CCS, or CIC certification/license • 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 setting • Preferred technology skills including Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers