Clinical Appeals Review RN, DRG

Why This Role Matters

Behind every denied claim is a clinical decision that deserves a thorough and objective review. As a Clinical Appeals Review RN DRG, your expertise plays a vital role in identifying opportunities to overturn denials. After review of the denial and medical record, the Clinical Appeals Review Nurse will provide either a reasoned explanation why no appeal can be written, or a detailed appeal letter based on current coding and regulatory guidelines and clinical criteria. In either case the Nurse will then track and trend MRI defined denial root causes for each specific denial.

What You’ll Gain

Flexibility of a remote work environment
Visibility and access to leadership
Opportunity to contribute ideas and influence change
Professional development and career growth opportunities
Meaningful work supporting healthcare organizations nationwide
A collaborative culture that values employee success, recognition, and work-life balance

What You’ll Do

Conduct secondary quality reviews of clinical appeal letters to ensure accuracy, clinical soundness, and compliance with coding, payer, and regulatory requirements prior to submission.
Perform efficient analysis of denied claims, pinpointing reason for denial and potential for success of appeal including correct allocation of diagnostic and procedural codes under ICD-10 Official Coding Guidelines and ICD-10 Procedural Coding Guidelines, 3M APR-DRG Classification System, CPT, HCPCS, Revenue Code, and All associated authorities such as CMS regulations, statutes, and associated authorities such as AHA Coding Clinics and CPT Assistant
Write clear and concise grammatically correct appeals letter in MRI format and to MRI quality standards
Be aware of the level of appeal, level of future appeals available and write according to the level of appeal
Utilize current applicable clinical, legal, and coding standards
Understand and strictly comply with time deadlines; write appeals in an efficient and timely manner
Provide a reasoned root cause analysis and summary review for all clients within MRI standard
At all time observe all HIPAA standards
Obtain and maintain client computer accesses
Participate in preparation of clear and concise audit report, as needed
Stay current in clinical, coding, and appeal writing areas and comply with MRI quality recommendations to maintain efficient and effective processes
Identify coding and clinical documentation issues and provide proactive recommendations through manager to clients
Identify problem account and seek review or return to client through manager, as appropriate
Clearly and concisely update patient account record to identify actions taken on account
Responsible to work through manager to liase with third party payer and agencies regarding appeals to ensure optimal reimbursement and resolve billing issues, contract misrepresentations and payment discrepancies

What You’ll Bring

Registered Nurse (BSN preferred)

CCS, CPC, CCDS, or RHIT Certification is required 
Graduate of an accredited College or University, BSN is preferred 
5+ years of clinical experience in Hospital inpatient and outpatient departments 
2+ years of clinical appeals/denials writing experience 
Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party) 
Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. (3M, Nuance, Epic, etc)