Clinical Appeals Specialist

The Clinical Appeals Specialist is responsible for reviewing and preparing clinical and coding-related appeals for denied or downgraded healthcare claims. This role involves analyzing medical documentation, applying ICD-10 coding guidelines, and utilizing MCG/InterQual criteria to support medical necessity and DRG validation. The ideal candidate has experience in clinical appeals writing, medical coding, CDI, or DRG downgrade review within a US healthcare environment.

Key Responsibilities

• Review denied, downgraded, or disputed healthcare claims and prepare comprehensive appeal documentation
• Analyze medical records to support medical necessity and coding accuracy
• Interpret and apply ICD-10-CM/PCS coding guidelines, MCG, and InterQual criteria
• Evaluate DRG assignments, including MS-DRG and APR-DRG methodologies
• Prepare clear, concise, and evidence-based clinical appeal letters
• Collaborate with coding, CDI, utilization review, and clinical teams to gather supporting documentation
• Ensure compliance with payer guidelines, CMS regulations, and organizational standards
• Maintain productivity, quality, and turnaround time expectations
• Identify trends or recurring denial patterns and escalate concerns when necessary
• Participate in process improvement initiatives and team discussions

Qualifications

• At least 6 months to 1+ year of Clinical Appeals Writing experience
• Experience handling DRG downgrade appeals or coding appeals preferred
• Background in Medical Coding, Clinical Documentation Improvement (CDI), or DRG validation/review
• Strong understanding of ICD-10 coding guidelines
• Familiarity with MCG and/or InterQual guidelines
• Experience with MS-DRG and APR-DRG methodologies is highly preferred
• US healthcare industry experience required
• Excellent analytical, critical thinking, and written communication skills
• Ability to work independently in a remote setup