Clinical Denial Specialist - Diagnosis Related Grouping (DRG)

WVU Medicine; Core (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

SYSTEM West Virginia University Health System is seeking a Revenue Cycle Specialist focused on denial management and hospital billing audits. You will collaborate with clinical and administrative staff to gather documentation and ensure accurate coding and DRG assignments.

The role emphasizes submitting timely appeals, maintaining compliance with CMS guidelines, and driving revenue recovery through proactive analysis and education across the department.

Qualifications

• Associate degree in healthcare administration, Nursing, Health Information Management, or related field and 5 years hospital billing experience
• Bachelor’s degree in healthcare administration, Nursing, Health Information Management, or related field and 3 years hospital billing experience
• Licenses or certifications: RN/LPN or RHIT/RHIA or CCDS/CDIP/CCS/CIC
• Two (2) years of hospital appeals/denials experience preferred
• Seven (7) years in hospital billing, CDI, or revenue cycle preferred

Responsibilities

• Review and respond to enterprise hospital billing audits promptly
• Collaborate with CRC educators for content and trends
• Prepare and submit clinical appeal documentation for denials
• Evaluate medical records for UHDDS guidelines and DRG accuracy
• Identify discrepancies between billed and documented services
• Calculate discrepancy dollar amounts and submit adjustments
• Negotiate with payers and provide supporting documentation
• Maintain denial databases and support organizational goals

Skills

Hospital billing

Denials/appeals

Revenue cycle

CMS guidance

Education

Associate degree in healthcare administration|Nursing|HIM

Bachelor’s degree in healthcare administration|Nursing|HIM

RN license (state/CIC inc)

LPN license (state)

RHIT

RHIA

CCDS

CDIP

CCS

CIC

Tools

Epic

Excel

Solventum

Wellington

MSDRG/DRG groupers

Job description

Minimum Qualifications

Education, Certification, and/or Licensure

• 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)

Experience

PREFERRED QUALIFICATIONS:

• Two (2) years of hospital appeals/denials, HIM or compliance experience
• Seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle setting.
• Strong technology skills including but not limited to Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers.

Core Duties and Responsibilities

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• Manage the timely review of and response to enterprise hospital billing audits received electronically and via postal mail.
• Collaborates with all CRC educators for educational content, opportunities and trends.
• Initiates and facilitates feedback loop for all stakeholders as appropriate.
• Completes clinical appeal writing for insurance denials.
• Evaluates each patient medical record reviewing specific documents and clinical relevance, relating to patient treatment, applying UHDDS guidelines, procedure relevancy, DRG accuracy, complications and comorbid structure.
• Identifying services billed versus services documented as rendered and clinically relevant.
• Identifies acceptable versus unacceptable supportive information, based on CMS/ Coding Rules and Guidelines/Clinical Practice Standards.
• Calculates the dollar total amounts for each discrepancy and submits necessary documents for adjustments, tracking and trending.
• Negotiates with external auditors regarding billing issues as needed to reach agreement on disputed items; provides appropriate supportive documentation for questioned charges.
• Completes and submits audit documentation in a timely fashion and legible manner. Completes work independently with minimum supervision.
• Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for clinical documentation clarifying what is found in the medical record as appropriate.
• Maintains current clinical and coding knowledge through reading, attendance at seminars, coding clinics, webinars, internal and external mandatory and informal education sessions.
• Provides timely information regarding bill defense problems to manager, and offers recommendations to eliminate the unnecessary loss of revenue
• Participates in departmental projects and educational opportunities to enhance effectiveness of the audit unit. Coordinates and presents education to various groups within the hospital directed at identified problems
• Develops appropriate learning tools and objectives for presentations. Shares knowledge with others in a clear, concise and timely manner.
• Responsible for all administrative activities with regard to denial management including: Collects all denial correspondence, updates the denial database regularly to accurately reflect all denials received, coordinates appeals process with all stakeholders.
• Aggressively appeals denials with payers to obtain maximum recovery of revenues.
• Attends all denial related meetings, as appropriate, to stay up to date on current organizational activities with regard to denials.
• Applies regulatory knowledge regarding payer policies, CMS guidelines, coding conventions and hierarchical rules.
• Provides support and assistance to Revenue Cycle Leadership as directed.
• Directs all referrals for further appeal to outside agencies based on department guidelines.
• Provides process improvement initiatives through route cause analysis.
• Works cooperatively with enterprise Compliance, HIM/ROI, and other departments as needed to ensure timely response.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Standard Work Environment.

Additional Job Description

Scheduled Weekly Hours: 40

Exempt/Non-Exempt

Shift: United States of America (Exempt)

Company: SYSTEM West Virginia University Health System

Cost Center: 553 SYSTEM Utilization Review