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, u...