Clinical Documentation Specialist - DRG Appeals

Catholic Health Services; Melville (NY); On-site; USD 130,000 - 170,000; Full time

Benefits offered by this job

Tuition assistance

Defined benefit pension

Benefits package

Job summary

Catholic Health is seeking a skilled CDI/DRG appeals specialist to support the DRG Appeals Shared Service. You will analyze denials, validate diagnoses, and manage the complete appeals process through all payor levels using ICD-10-CM/PCS guidelines and clinical documentation review.

The role requires five years of hospital-based clinical experience, two years in inpatient CDI, and CCDS certification, with strong collaboration with physicians and HIM teams.

Qualifications

• BSN degree or NP/PA license required.
• Current NYS license.
• CCDS certification required.
• Five years clinical experience in acute hospital setting.
• Minimum of 2 years inpatient CDI experience.
• Proficiency in ICD-10-CM/PCS and coding guidelines.
• Strong communication and multitasking abilities.

Responsibilities

• Initiate and follow through for all RAC and Third Party Payor denials at every level, reviews all denials with direct report for plan/strategy for appeal.
• Must be able to meet or exceed appeal deadline completion times.
• Involve appropriate physicians in the appeal process expanding into the preparation for ALJ and DRA.
• Follow up Third Party Payor responses to all appeals and update RAC and Third Party Payor focus studies, as well as Epic revenue cycle with attention to detail.
• Communicate denial issues with site HIM/CDIP Department and patient accounts.
• Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation, clinical validation for inpatient diagnoses that impact the code selection, resulting DRG, and payment.
• Working knowledge of AHA Coding Clinics.
• Working knowledge of encoder, ability to correct coding and re-drop bill.
• Communicates with physician advisor, or attending physician verbally or through written methodology to validate diagnosis in question and support appeal.
• Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement, and participates with the planning and development of educational programs directed towards improving documentation.
• Participates in education programs to maintain up to date coding skills.

Skills

MS Office

Independent work

Education

BSN

NP or PA license

Tools

Epic

Encoder

Job description

Overview

Catholic Health is one of Long Island’s finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, three nursing homes, a home health service, hospice and a network of physician practices across the island.

At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes – to every patient, every time.

We are committed to caring for Long Island. Be a part of our team of healthcare heroes and discover why Catholic Health was named Long Island's Top Workplace!

Job Details

Conducts timely DRG Appeals supporting the CHS DRG Appeals Shared Service. Analyzes denials and appeals cases as appropriate. Determines accuracy of coding based upon review of the medical documentation and application of the coding guidelines. Clinically validates diagnoses in question. Manages the complete appeals process through all levels of appeal according to payor contract.

DUTIES/RESPONSIBILITIES:

• Initiate and follow through for all RAC and Third Party Payor denials at every level, reviews all denials with direct report for plan/strategy for appeal.
• Must be able to meet or exceed appeal deadline completion times.
• Involve appropriate physicians in the appeal process expanding into the preparation for ALJ and DRA.
• Follow up Third Party Payor responses to all appeals as appropriate and update RAC and Third Party Payor focus studies, as well as Epic revenue cycle with attention to detail.
• Communicate denial issues with site HIM/CDIP Department and patient accounts.
• Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation, clinical validation for inpatient diagnoses that impact the code selection, resulting DRG, and payment.
• Working knowledge of AHA Coding Clinics
• Working knowledge of encoder, ability to correct coding and re-drop bill.
• Communicates with physician advisor, or attending physician verbally or through written methodology to validate diagnosis in question and support appeal.
• Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement, and participates with the planning and development of educational programs directed towards improving documentation.
• Participates in education programs to maintain up to date coding skills.

POSITION REQUIREMENTS AND QUALIFICATIONS:

Education:

• Bachelors of Science in Nursing, OR
• NP or PA license.

Licensure/Certification:

• Current NYS License.
• Certification: CCDS required

Skills:

• Proficient computer skills for Windows Microsoft Office Applications (Word, Excel, Power Point)
• Self-motivated, self-directed, and able to work independently with minimal supervision.

Experience:

Five years clinical experience in Acute Hospital setting. Minimum of 2 years inpatient CDI experience.

Proficiency in ICD-10-CM and PCS Official Guidelines for Coding and Reporting

Other:

Multitasking, excellent communication and critical thinking skills.

Salary Range

USD $130,000.00 - USD $170,000.00 /Yr.

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.