DRG Appeals Specialist

Key Responsibilities:

• Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.

• Analyze payer denials involving: o DRG downgrades o Removal of CC/MCC o Clinical validation denials o Coding validation disputes.

• Prepare clear, concise, and compliant DRG appeal letters supported by:

o ICD-10-CM/PCS Official Guidelines

o UHDDS reporting requirements

o CMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)

• Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards

• Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases

• Ensure timely filing of appeals in accordance with payer and client deadlines

• Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time

• Participate in quality audits, peer reviews, and continuous process improvement initiatives

• Maintain strict compliance with HIPAA and data privacy regulations.

Required Qualifications:

• Inpatient Coding Experience (required)

• Strong working knowledge of:

o ICD-10-CM and ICD-10-PCS

o MS-DRG and APR-DRG systems

o CC/MCC logic and DRG impact

• Demonstrated experience handling DRG appeals or inpatient coding denials

• Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.

• Excellent written communication skills with the ability to cite official coding and clinical references.

• High attention to detail, critical thinking, and strong analytical skills.

• Ability to work independently while meeting productivity and quality benchmarks