DRG Appeals Nurse

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

The DRG Appeals Specialist performs reviews of inpatient DRG payer denials on behalf of our hospital client partners. Responsibilities include reviewing denial letters, determination and data entry of audit recommendations, and responsibility for professional and effective appeal responses that are submitted timely under payer timeframes.  

MUST HAVES:

Current and valid RN license
DRG validation experience
Medical necessity experience and appeal letter writing

Coding certification (AHIMA or AAPC) is a plus

This position is 100% onsite with occasional requirement to travel to multiple sites within an average 30-mile* radius

seeking to cover central region (Indianapolis)

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

CorroHealth is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. CorroHealth has expanded its product offering to include DRG Revenue Integrity services. CorroHealth provides programmatic solutions for DRG compliance and revenue integrity by leveraging advanced analytics and DRG auditing and clinical expertise. CorroHealth offers outstanding growth opportunities, a competitive salary and flexible work environments. CorroHealth has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Responsibilities:  

• Performs comprehensive reviews of inpatient medical records to validate the MS/APR DRGs assigned for Medicare, Commercial, and Third-Party paid claims.  

• Validates that all ICD-10-CM/PCS, discharge disposition codes, and Hospital Acquired Condition (HAC), Present on Admission (POA) indicators impacting payment are documented, clinically supported, and assigned following Official Coding Guidelines, compliant query practices and current clinical validation criteria.  

• Utilizes audit reference tools and applications (e.g., proprietary denials management application, TruCode, and 3M encoder and grouper software and references). 

• Reviews denial letters rationale and formulates custom appeal response letters utilizing strong critical thinking skills to independently access cases for strengths and weaknesses within the appeals spectrum. Constructs and documents a brief and fact-based case utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine, and official coding guidelines. Applies strong writing and grammar skills to formulate professional appeal letters that clearly support each appeal argument.  

• Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures. 

• Maintains subject matter expertise in clinical validation criteria and practices, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies.  

• Attends continuing education workshops, webinars, etc., for coding and documentation integrity and compliance. 

• Other responsibilities as assigned. Duties may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing. 

Required Education/Experience: 

• Active RN license in good standing required

• CCS preferred after one year of employment. (Assistance is available for preparation.) RHIT/RHIA/CPC is a plus

• CDIP or CCDS is highly preferred.   

• Professional license (RN) must be maintained as a condition of employment. 

• A minimum of 5 years of experience in any of the following roles: 

• Inpatient coding quality assurance 

• DRG validation 

• DRG appeal 

• Clinical Documentation Integrity (CDI) as a Clinical Documentation Specialist (CDS), Educator, or Manager 

Skills:  

• Extensive Inpatient Coding Skills. Possess regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS/APR DRG payment methodologies, including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.  

• Clinical Validation Skills. Demonstrate the ability to identify, apply, and validate the use of current industry standard clinical indicators, risk factors and treatment protocols used in clinical validation of payment impacting code assignment. Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, disease assessment, management and treatment is required. 

• Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes, and evaluates information gathered from, or generated by observation, experience, reflection, reasoning, or communication as a guide to validate audit results and correct, as necessary. 

• Adaptability. Maintains effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures. 

• Initiative. Is proactive and self-directed. Show initiative and responsibility in taking the necessary steps towards problem resolution. Is self-sufficient and does not need to rely on others to complete a job.  

• Vivacity. Consistently maintains high levels of activity or productivity sustained over long working hours when necessary; operates with vigor, effectiveness, and determination. 

• Performance. Meets or exceeds both production and quality expectations while performing complex medical record audits. Able to execute under pressure of time constraints and while managing multiple responsibilities.  

• Planning and Organization. Proactively prioritizes initiatives, effectively manages resources and can multi-task. Actively manages their work assignments and seeks additional tasks when appropriate.   

• Communication Skills. Communicates clearly, proactively, and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise rationales in support of findings and successfully crafts appeal letters with precise logic. 

• Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail, identifies aberrant code assignment, mines medical records for all relevant and supporting evidence, intuitively understands appeal strategies and conscientiously follows all steps in the audit and appeals process.  Committed to life-long learning.  

• PC Skills. Demonstrates proficiency in Microsoft Office and Teams, WebEx, VPN access, navigating various EHRs, and ability to problem solve Internet connectivity issues.  

Benefits 

• Enjoy work-life balance with a predictable schedule  

• Compensation includes salary plus bonus opportunities 

• Medical, Dental, Vision coverage, 401K 

• Holidays, paid time off, short term and long-term disability insurance, and life insurance 

• Reimbursement for continuing education and association dues 

This position is 100% onsite with requirement to travel to multiple sites within an average 30-mile* radius

seeking to cover central region (Indianapolis)

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.