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 DRG downgrades, removal of CC/MCC, clinical validation denials, and coding validation disputes.
• Prepare clear, concise, and compliant DRG appeal letters supported by ICD‑10‑CM/PCS official guidelines, UHDDS reporting requirements, 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 qualit...