DRG Denials & Appeals Specialist

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

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.