Remote Senior Clinical Appeals RN: DRG & Coding Expert

Optum; Plymouth (MN); On-site; USD 48,000 - 87,000; Full time

Benefits offered by this job

Remote work in the U.S.

Competitive benefits

Job summary

Optum Insight is seeking a Senior Clinical Appeals RN to apply MS-DRG and APR-DRG auditing expertise in reviewing appeals. You will work with original auditors, review medical records, and mentor remote DRG Validation Specialists.

The role emphasizes coaching, timely written documentation, and collaboration across the team. You will analyze DRG appeals, respond to higher levels of appeals, and provide guidance to the broader auditing organization while maintaining clinical and coding accuracy.

Qualifications

• Unrestricted RN license in your state of residence.
• CCS or CIC certification or willing to obtain within 6 months of hire.
• 2+ years of ICD-10-CM coding experience including primary diagnosis, CCs/MCCs, SOI, ROM.
• 2+ years of ICD-10-PCS coding knowledge including body systems, root operations, and devices.

Responsibilities

• Analyze scope and resolution of DRG Appeals.
• Respond to Level one, two or higher appeals.
• Perform complex conceptual analyses.
• Identify risk factors, comorbidities, adverse events, determine overpayments/adjustments.
• Review regulations and payer policies to recommend actions.
• Research and prepare written appeals.
• Exercise clinical and coding judgment in audits.
• Collaborate with auditors, quality and leadership to review medical records.

Skills

RN licensure

CCS or CIC

ICD-10-CM coding

ICD-10-PCS coding

Education

RHIT

RHIA

CDIP

CCS

CIC

Tools

MS Excel

Job description

Optum Insight is seeking a Senior Clinical Appeals RN to apply MS-DRG and APR-DRG auditing expertise in reviewing appeals. You will work with original auditors, review medical records, and mentor remote DRG Validation Specialists.

The role emphasizes coaching, timely written documentation, and collaboration across the team. You will analyze DRG appeals, respond to higher levels of appeals, and provide guidance to the broader auditing organization while maintaining clinical and coding accuracy.