Revenue Integrity Clinician: DRG & Appeals Expert

Second Wave Delivery Systems, LLC; Las Vegas (NV); Presencial; USD 90 000 - 130 000; Tempo integral

Resumo da oferta

Second Wave Delivery Systems, LLC is seeking a cross-functional Revenue Integrity CDI specialist. The role centers on clinical documentation integrity, DRG validation, and denial-prevention activities across payers including Medicare and Medicaid.

The ideal candidate has RN licensure or coding credentials, 5+ years in CDI/denials, and proficiency with EHR systems and encoding tools. This position emphasizes evidence-based appeal writing and cross-disciplinary collaboration.

Qualificações

• Current RN license or professional coding credential required.
• Bachelor’s degree in nursing, Health Information Management, or a related healthcare field preferred.
• Minimum of five years of experience in Clinical Documentation Integrity (CDI), inpatient coding, denials management, clinical validation, DRG validation, or revenue cycle operations.
• Minimum of three years of experience writing successful payer appeals preferred.
• Experience reviewing Medicare, Medicare Advantage, Medicaid, RAC, and commercial insurance denials.
• Demonstrated experience with electronic health record (EHR) systems and encoder applications.
• One or more of the following certifications preferred: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC.

Responsabilidades

• Review denied claims involving DRG downgrades, clinical validation and coding denials.
• Draft clear, persuasive, evidence-based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.
• Prepare first-level and second-level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.
• Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, AKI, malnutrition, encephalopathy, and other MCC/CC conditions.
• Validate coding accuracy, DRG assignment, principal diagnosis selection, present-on-admission indicators, and reimbursement determinations.
• Track appeal outcomes, recovered revenue, overturn rates, and denial trends for reporting and continuous improvement.
• Participate in client education initiatives focused on denial prevention, documentation improvement, and coding accuracy.
• Maintain productivity during fluctuations in denial volume by independently conducting DRG audits, coding compliance reviews, clinical validation assessments, and denial-prevention initiatives.

Conhecimentos

Clinical Documentation Integrity

Payer appeals

Analytical thinking

Written communication

Cross-functional collaboration

Formação académica

Bachelor’s degree in nursing/health info management or related field

RN license or professional coding credential

Ferramentas

3M Encoder

Epic

Cerner

TruCode

Optum

Descrição da oferta de emprego

Second Wave Delivery Systems, LLC is seeking a cross-functional Revenue Integrity CDI specialist. The role centers on clinical documentation integrity, DRG validation, and denial-prevention activities across payers including Medicare and Medicaid.

The ideal candidate has RN licensure or coding credentials, 5+ years in CDI/denials, and proficiency with EHR systems and encoding tools. This position emphasizes evidence-based appeal writing and cross-disciplinary collaboration.