Remote Senior Clinical Appeals RN | DRG & Coding

Optum

Plymouth (MN)

On-site

USD 48,000 - 87,000

Full time

2 days ago

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Job summary

Optum is seeking a Senior Clinical Appeals RN to review DRG Appeals, coordinate with auditors, and provide guidance to DRG validation specialists. You will analyze scope, respond to appeals, and ensure accurate documentation under tight deadlines while applying MS-DRG and APR-DRG knowledge. This remote role allows work from anywhere in the U.S.

and offers comprehensive benefits. You will navigate web portals, review medical records, and collaborate with leadership to improve risk and

Qualifications

Unrestricted RN license in your state of residence.
CCS or CIC certification or willing to obtain within 6 months of hire.
Two or more years of ICD-10-CM coding experience including principal diagnosis selection and CC/MCC concepts.
Two or more years of ICD-10-PCS coding experience including body systems, root operations, and qualifiers.
Proficiency with MS Excel and ability to navigate web-based portals.

Responsibilities

Analyze scope and resolution of DRG Appeals.
Respond to Level one, two or higher appeals.
Perform complex conceptual analyses.
Identify risk factors and comorbidities to determine if overpayment or adjustment is needed.
Review governmental regulations and payer policies to recommend actions.
Research and prepare written appeals.
Collaborate with auditors, quality, and leadership on reviewed cases.
Develop and communicate business requirements.