Clinical Denial Specialist - Diagnosis Related Grouping (DRG)

About the role

Responsible for all administrative activities surrounding management, timely review/appeal, reporting, monitoring, and analyzing hospital-based clinical, coding, and diagnosis-related grouping denials. This role ensures the accuracy and integrity of billed services by conducting comprehensive reviews of patient medical records, validating clinical relevance, assessing DRG accuracy, and identifying discrepancies between documentation and billed charges. The specialist prepares and submits detailed clinical appeals, negotiates with external auditors, and applies regulatory knowledge—including CMS guidelines, coding rules, and clinical standards—to support the organization’s position. The DRG Clinical Denial Specialist collaborates with clinical, coding, revenue cycle, and educational stakeholders to support ongoing process improvement, develop educational materials, and enhance organizational compliance and documentation quality. The coordinator is expected to work independently with minimal supervision while maintaining current clinical and coding knowledge and representing the organization effectively in communications with payers and external auditors.

Responsibilities

• Manage the timely review of and response to enterprise hospital billing audits received electronically and via postal mail.
• Collaborate with all CRC educators for educational content, opportunities, and trends.
• Initiate and facilitate feedback loops for all stakeholders as appropriate.
• Complete clinical appeal writing for insurance denials.
• Evaluate each patient medical record, reviewing specific documents and clinical relevance relating to patient treatment, applying UHDDS guidelines, procedure relevancy, DRG accuracy, complications, and comorbid structure.
• Identify services billed versus services documented as rendered and clinically relevant.
• Identify acceptable versus unacceptable supportive information based on CMS/Coding Rules and Guidelines/Clinical Practice Standards.
• Calculate the dollar total amounts for each discrepancy and submit necessary documents for adjustments, tracking, and trending.
• Negotiate with external auditors regarding billing issues as needed to reach agreement on disputed items; provide appropriate supportive documentation for questioned charges.
• Complete and submit audit documentation in a timely and legible manner.
• Complete work independently with minimum supervision.
• Communicate regularly with clinical and administrative personnel to obtain further supportive documentation for clinical documentation clarifying what is found in the medical record as appropriate.
• Maintain current clinical and coding knowledge through reading, attendance at seminars, coding clinics, webinars, internal and external mandatory and informal education sessions.
• Provide timely information regarding bill defense problems to manager and offer recommendations to eliminate unnecessary loss of revenue.
• Participate in departmental projects and educational opportunities to enhance the effectiveness of the audit unit.
• Coordinate and present education to various groups within the hospital directed at identified problems.
• Develop appropriate learning tools and objectives for presentations.
• Share knowledge with others in a clear, concise, and timely manner.
• Collect all denial correspondence and update the denial database regularly to accurately reflect all denials received.
• Coordinate appeals process with all stakeholders.
• Aggressively appeal denials with payers to obtain maximum recovery of revenues.
• Attend all denial-related meetings, as appropriate, to stay up to date on current organizational activities regarding denials.
• Apply regulatory knowledge regarding payer policies, CMS guidelines, coding conventions, and hierarchical rules.
• Provide support and assistance to Revenue Cycle Leadership as directed.
• Direct all referrals for further appeal to outside agencies based on department guidelines.
• Provide process improvement initiatives through root cause analysis.
• Work cooperatively with enterprise Compliance, HIM/ROI, and other departments as needed to ensure timely response.

Requirements

Education, Certification, and/or Licensure

• Associate degree in healthcare administration, Nursing, Health Information Management, or related field AND five (5) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle.
• OR Bachelor’s degree in healthcare administration, Nursing, Health Information Management, or related field AND three (3) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle.
• Certification or License in one of the following:
  • Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
  • Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
  • Registered Health Information Technician (RHIT) through the American Health Information Management Association (AHIMA).
  • Registered Health Information Administrator (RHIA) through the American Health Information Management Association (AHIMA).
  • Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialist (ACDIS).
  • Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association (AHIMA).
  • Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA).
  • Certified Inpatient Coder (CIC) through the American Academy of Professional Coders (AAPC).

Preferred Qualifications

• Two (2) years of hospital appeals/denials, HIM, or compliance experience.
• Seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle setting.
• Strong technology skills including but not limited to Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Standard work environment.

Schedule

Scheduled weekly hours: 40. Shift: Day. Exempt status.