DRG Appeals Specialist

Health Business Solutions LLC; Philippines; On-site; PHP 279,000 - 390,600; Full time

Job summary

A healthcare solutions company is seeking a skilled individual to handle inpatient coding and DRG appeals in the Philippines. You will review medical records, analyze payer denials, and prepare compliant appeal letters while maintaining compliance with HIPAA regulations. The ideal candidate has strong expertise in ICD-10 coding, exceptional written communication skills, and the ability to work independently. Join us to support quality initiatives and improve coding accuracy within the healthcare sector.

Qualifications

• Inpatient Coding Experience is required.
• Strong working knowledge of ICD-10-CM and ICD-10-PCS is expected.
• Experience with DRG appeals or inpatient coding denials is essential.

Responsibilities

• Review inpatient medical records and validate diagnoses and procedures.
• Analyze payer denials, including DRG downgrades and clinical validation.
• Prepare compliant DRG appeal letters using official guidelines.
• Defend secondary diagnoses based on documentation and standards.
• Collaborate with teams to resolve complex cases.
• Maintain compliance with HIPAA and privacy regulations.

Skills

Inpatient Coding Experience

ICD-10-CM and ICD-10-PCS knowledge

Analysis of DRG appeals

Attention to detail

Excellent written communication

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
  • 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 and ICD-10-PCS
  • MS-DRG and 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 the 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.