Clinical DRG Denials Specialist

SUMMARY:
The Clinical DRG Denials Specialist applies clinical knowledge, coding principles, payer policy interpretation, and documentation review to support appropriate reimbursement and regulatory compliance and works to protect organizational reimbursement by ensuring the accurate review, appeal, and resolution of DRG-related payer denials. Additionally, the position proactively works to identify documentation and coding risks before claim submission to reduce avoidable denials and strengthen revenue integrity. Through analysis of denial trends and appeal outcomes, the role helps improve processes and support denial prevention strategies across the revenue cycle.

RESPONSIBILITIES:

• Ensures accurate and timely resolution of DRG-related payer denials and audit activity in order to protect reimbursement and minimize avoidable revenue loss.
• Produces well-supported and compliant appeal outcomes by applying clinical, coding, and payer policy knowledge to disputed DRG determinations.
• Maintains adherence to contractual, regulatory, and documentation requirements across denial, appeal, and pre-bill review activities to support compliance and payment integrity.
• Strengthens revenue integrity by identifying and addressing documentation, coding, and medical necessity risks before claim submission.
• Improves denial prevention performance through analysis of payer trends, denial patterns, and appeal outcomes, leading to responsive strategies and process enhancements.
• Ensures denial-related information, requirements, and case status are consistently maintained to support accurate tracking, reconciliation, and operational visibility.
• Promotes effective, standardized denial and appeal practices that support efficient workflows and consistent organizational response to payer challenges.
• Applies specialized clinical and coding expertise to support accurate DRG assignment, documentation integrity, and sustainable reimbursement outcomes across the revenue cycle.

REQUIRED QUALIFICATIONS:

• Degree in Nursing

• NYS Registered Nurse Licensure

PREFERRED QUALIFICATIONS:

• Knowledge of Epic preferred

• Proficient in Microsoft Office applications preferred

• Practical experience with computerized encoding and grouping software preferred

• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist certification (CCS) preferred.

• BSN preferred.