DRG and Clinical Appeals Specialist

Second Wave Delivery Systems, LLC; Las Vegas (NV); On-site; USD 90,000 - 130,000; Full time

Job summary

Second Wave Delivery Systems, LLC is seeking a cross-functional Revenue Integrity CDI specialist. The role centers on clinical documentation integrity, DRG validation, and denial-prevention activities across payers including Medicare and Medicaid.

The ideal candidate has RN licensure or coding credentials, 5+ years in CDI/denials, and proficiency with EHR systems and encoding tools. This position emphasizes evidence-based appeal writing and cross-disciplinary collaboration.

Qualifications

• Current RN license or professional coding credential required.
• Bachelor’s degree in nursing, Health Information Management, or a related healthcare field preferred.
• Minimum of five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations.
• Minimum of three years of experience writing successful payer appeals preferred.
• Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials.
• Demonstrated experience with electronic health record (EHR) systems and encoder applications.
• One or more of the following certifications preferred: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC.

Responsibilities

• Review denied claims involving DRG downgrades, clinical validation and coding denials.
• Draft clear, persuasive, evidence-based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.
• Prepare first-level and second-level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.
• Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, AKI, malnutrition, encephalopathy, and other MCC/CC conditions.
• Validate coding accuracy, DRG assignment, principal diagnosis selection, present-on-admission indicators, and reimbursement determinations.
• Track appeal outcomes, recovered revenue, overturn rates, and denial trends for reporting and continuous improvement.
• Participate in client education initiatives focused on denial prevention, documentation improvement, and coding accuracy.
• Maintain productivity during fluctuations in denial volume by independently conducting DRG audits, coding compliance reviews, clinical validation assessments, and denial-prevention initiatives.

Skills

Clinical Documentation Integrity

Payer appeals

Analytical thinking

Written communication

Cross-functional collaboration

Education

Bachelor’s degree in nursing/health info management or related field

RN license or professional coding credential

Tools

3M Encoder

Epic

Cerner

TruCode

Optum

Job description

This position is designed as a cross-functional revenue integrity role. While primary responsibilities focus on clinical and DRG appeals, the specialist is expected to support DRG validation audits, coding compliance reviews, clinical validation initiatives, and denial-prevention activities during periods of lower appeals volume. Flexibility and the ability to work across multiple revenue cycle disciplines are essential requirements of the position.

Key Responsibilities

Review denied claims involving DRG downgrades, clinical validation and coding denials.

Conduct a comprehensive analysis of medical records, coded data, physician documentation, laboratory results, imaging findings, treatments, and patient outcomes to identify appeal opportunities.

Draft clear, persuasive, evidence-based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.

Prepare first-level and second-level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.

Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, acute kidney injury, malnutrition, encephalopathy, and other MCC/CC conditions, using evidence-based practice and literature.

Validate coding accuracy, DRG assignment, principal diagnosis selection, present-on-admission indicators, and reimbursement determinations.

Research and incorporate peer-reviewed clinical literature, specialty society guidance, and regulatory references to support appeal positions.

Track appeal outcomes, recovered revenue, overturn rates, and denial trends for reporting and continuous improvement.

Participate in client education initiatives focused on denial prevention, documentation improvement, and coding accuracy.

Maintain productivity during fluctuations in denial volume by independently conducting DRG audits, coding compliance reviews, clinical validation assessments, pre-bill revenue integrity reviews, and denial-prevention initiatives to support organizational revenue cycle objectives

Qualifications

Education and Experience

Current RN license or professional coding credential required.

Bachelor’s degree in nursing, Health Information Management, or a related healthcare field preferred.

Minimum of five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations.

Minimum of three years of experience writing successful payer appeals preferred.

Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials.

Demonstrated experience working with electronic health record (EHR) systems and encoder applications.

Proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI or coding technologies preferred.

One or more of the following certifications preferred: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC.

Knowledge, Skills, and Abilities

Advanced knowledge of ICD-10-CM/PCS coding guidelines, MS-DRG and APR-DRG methodologies, and reimbursement systems.

Strong understanding of clinical documentation integrity principles and clinical validation standards.

Exceptional analytical and critical-thinking skills, with the ability to interpret complex clinical records.

Excellent written communication skills, including the ability to develop concise, persuasive, and technically sound appeal letters.

Knowledge of CMS regulations, payer audit methodologies, Coding Clinic guidance, and industry best practices.

Ability to prioritize workload independently and

Demonstrated ability to function effectively in a flexible, cross-trained role, transitioning between denials and appeals activities, DRG validation, coding compliance auditing, clinical validation reviews, and other revenue integrity functions based on business needs

Clinical Expertise: Interprets clinical indicators, treatment patterns, and disease processes to support diagnosis validation.

Appeals Writing: Develops well-supported, evidence-based arguments designed to maximize overturn success rates.

Analytical Thinking: Identifies weaknesses in denial rationales and opportunities for reimbursement recovery.

Collaboration and Flexibilty: Partners effectively with physicians, CDI teams, coding professionals, and revenue cycle stakeholders.

Regulatory Knowledge: Applies CMS regulations, coding guidance, and payer policies accurately and consistently.

Results Orientation : Focuses on maximizing recovered revenue and reducing recurring denial patterns.