DRG Appeals Specialist — CDI & Denials Expert

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

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.