DRG Appeals Specialist

Health Business Solutions LLC; Pasig; On-site; PHP 420,000 - 620,000; Full time

Job summary

A healthcare solutions company is seeking an experienced medical coder to review inpatient records and handle DRG appeals. Responsibilities include analyzing payer denials and preparing DRG appeal letters in compliance with official coding guidelines. The ideal candidate will have strong knowledge of ICD‑10‑CM and experience in inpatient coding. This role also requires excellent communication skills and attention to detail to success in a fast-paced environment.

Qualifications

• Experience in reviewing inpatient medical records and coding standards.
• Ability to prepare compliant DRG appeal letters supported by official guidelines.
• Strong knowledge of CC/MCC logic and DRG systems.
• Ability to interpret complex medical records for defensible narratives.
• Strong written communication citing coding guidelines.
• High attention to detail and analytical thinking.
• Ability to work independently while meeting productivity goals.

Responsibilities

• Review inpatient medical records for validating diagnoses and procedures.
• Analyze payer denials related to DRG and coding validation disputes.
• Ensure compliance with HIPAA and maintain data privacy.
• Defend secondary diagnoses and MCC/CC assignments based on documentation.
• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve cases.
• Ensure timely filing of appeals per deadlines.
• Document appeal outcomes and maintain productivity/quality logs.
• Participate in quality audits and process improvement initiatives.
• Maintain HIPAA and data privacy compliance.

Skills

Inpatient coding experience

ICD‑10‑CM knowledge

CMS rules understanding

Attention to detail

Analytical skills

Excellent written communication

Attention to detail

Job description

Key Responsibilities

• Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.
• Analyze payer denials involving DRG downgrades, removal of CC/MCC, clinical validation denials, and coding validation disputes.
• Prepare clear, concise, and compliant DRG appeal letters supported by ICD‑10‑CM/PCS official guidelines, UHDDS reporting requirements, CMS rules, and industry references (e.g., AHA Coding Clinic, AHIMA guidance).
• Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards.
• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases.
• Ensure timely filing of appeals in accordance with payer and client deadlines.
• Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time.
• Participate in quality audits, peer reviews, and continuous process improvement initiatives.
• Maintain strict compliance with HIPAA and data privacy regulations.

Required Qualifications

• Inpatient coding experience (required).
• Strong working knowledge of ICD‑10‑CM, ICD‑10‑PCS, MS‑DRG, APR‑DRG systems, CC/MCC logic, and DRG impact.
• Demonstrated experience handling DRG appeals or inpatient coding denials.
• Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.
• Excellent written communication skills with ability to cite official coding and clinical references.
• High attention to detail, critical thinking, and strong analytical skills.
• Ability to work independently while meeting productivity and quality benchmarks.