Job Details
Job TypeFull-time
DescriptionThe Appeals and Denials Specialist is responsible for triaging and writing DRG downgrades and clinical validation appeal letters for multiple clients. The Appeals and Denials Specialist will ensure appropriate action is taken within appeal deadlines. This position collaborates with the Appeals and Denials team and other departments as needed.PRIMARY JOB RESPONSIBILITIES:Performs review of the medical record including documentation, reports, flowsheets, and test results, applying evidence-based criteria related to DRG and clinical validation denialsCreates appeal letters utilizing the relevant information from the medical record; supported by current clinical standards and facility guidelines, evidence-based medicine, professionally recognized standards of health care, and ICD-10-CM/PCS Official Coding GuidelinesIs flexible, able to navigate multiple EHRs and other databases used by Accuity or the client, performs reviews, and submits letters of appeal per the client specific workflowsAble to prioritize cases to meet appeal deadlinesDetail-orientedCollaborates with Accuity Physician and Accuity CDI in appropriately identified clinical denials requiring communication to the Accuity clinical review teamsMaintains clinical expertise and trends in healthcare, reimbursement methodologies and specialty areas by participating in professional organizations, seminars, and educational programsPerforms miscellaneous job-related duties as assigned
RequirementsPOSITION QUALIFICATIONS:Education :Associate or bachelor's degree in nursing or licensure in other clinical healthcare field such as MD, NP, PA.Experience:Minimum 3 years of CDI experienceor experience with clinical inpatient DRG Downgrades and clinical denialsLicensure and/or Credentials:At least one of the following: MD, RN, BSN, CCDS, CDIPKnowledge, Skills, and Abilities:Inpatient clinical experienceExtensive knowledge of revenue cycle management and coding servicesRequires good interpersonal and customer service skillsDemonstrated knowledge of ICD-10-CM, ICD-10-PCSMotivated and self-directedExperience with electronic health records and health information systemsOrganized and able to prioritize to ensure objectives are met in a timely mannerAbility to establish and maintain cooperative working relationships with physicians and staffAbility to use a PC in a Windows environment, including MS Word, Excel and PPTIndependent, focused individual able to work remotely
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