DRG (Coding) Appeal Reviewer

MedReview; New York (NY); Remote; USD 85,000 - 90,000; Full time

Job summary

An established industry player is seeking a skilled DRG Appeal Reviewer to ensure accuracy and compliance in healthcare billing. This role involves analyzing denied claims, collaborating with physician reviewers, and constructing detailed responses to providers. With a focus on clinical excellence, you'll thrive in a supportive environment that values your expertise and commitment to quality. Join a team dedicated to enhancing healthcare integrity while enjoying a comprehensive benefits package including healthcare options, 401(k) matching, and generous paid time off. If you have a passion for coding and a desire to make a meaningful impact, this opportunity is perfect for you.

Benefits

Excellent medical, dental, and vision plan options

401(k) with Employer Match

Generous Paid Time Off

Commuter Benefits

Learning & Development opportunities

Qualifications

• 5+ years of experience in MS-DRG and APR-DRG coding through acute care.
• Coding Certification required, with ongoing education to maintain credentials.

Responsibilities

• Review inpatient claims for accurate DRG assignment and coding compliance.
• Construct detailed response letters to providers regarding claims.

Skills

MS-DRG Coding

APR-DRG Coding

Attention to Detail

Written Communication

Verbal Communication

Organizational Skills

Problem-Solving

Education

Coding Certification (RHIA, RHIT, CCS, CIC)

College Courses in Medical Terminology

College Courses in Anatomy

College Courses in Pathophysiology

College Courses in Pharmacology

Tools

Outlook

Word

Excel

Job description

Position Summary

At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.

Under the direction of the DRG Operations Department leaders, the DRG Appeal Reviewer reviews and analyzes provider responses on denied/downgraded MS-DRG and APR-DRG claims to determine whether the downgraded DRG is substantiated after appeal and will construct a detailed response letter.

Responsibilities

1. Analyze and review inpatient claims following the Official Coding and Reporting Guidelines to validate the reported ICD-10-CM/PCS codes to ensure proper DRG assignment for accurate billing.
2. Demonstrates the ability to perform a comprehensive initial review as outlined in the standard operating procedures and departmental guides.
3. Construct professionally written and detailed responses to providers current coding and regulatory guidelines applicable to the downgraded claim.
4. Collaborates with physician reviewers, as needed.
5. Ability to prioritize and organize workload and complete tasks independently.
6. Required attendance of all departmental team meetings and/or training.
7. Work on other duties or tasks, as necessary.

Performance Expectations

1. Report productivity daily utilizing department productivity report.
2. Meet/exceed productivity expectations as outlined in the department productivity policy.
3. Maintains 95% accuracy in claim reviews.
4. Complies with organization policy and procedures.

Qualifications

1. Coding Certification required (at least one of the following is required and must be maintained as a condition of employment):

• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Inpatient Coder (CIC)
• Candidates with a Registered Health Information Technician (RHIT)

Other credential consideration:

• Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) or Certified Professional Coder (CPC) will be considered but will need to obtain an inpatient coding certification (CCS or CIC) within 12 months of hire.

College level courses in medical terminology, anatomy, pathophysiology, pharmacology, and medical coding courses.

5+ years of experience in MS-DRG and APR-DRG coding experience through acute care inpatient coding, auditing, and/or payment integrity DRG Validation.

At least 2 years of appeal experience through the acute care setting and/or payment integrity DRG Validation.

Adherence to the Official Coding and Reporting guidelines, AHA Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates.

Requires working knowledge of applicable industry-based standards.

Proficiency in Outlook, Word, Excel, and other applications.

Excellent written and verbal communication skills.

Maintain professional credentialed status with approved continuing education programs.

Ability to work independently and can multi-task or transition to different tasks easily.

Remote Work Requirements

1. High speed internet (100 Mbps per person recommended) with secured WIFI.
2. A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
3. Must be able to sit and use a computer keyboard for extended periods of time.

Benefits and perks include:

1. Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
2. 401(k) with Employer Match - Join the team and we will invest in your future.
3. Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays.
4. Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered.
5. Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.

Salary Range: $85,000-90,000/ annually.