Clinical Documentation Specialist - DRG Appeals

Catholic Health is one of Long Island’s finest health and human services agencies. Our health system includes over 16,000 employees, six acute care hospitals, three nursing homes, a home health service, hospice, and a network of physician practices across the island. We work collaboratively to provide compassionate care and utilize evidence-based practice to improve outcomes for every patient, every time.

About the role

Conducts timely DRG Appeals supporting the CHS DRG Appeals Shared Service. Analyzes denials and appeals cases as appropriate. Determines accuracy of coding based upon review of the medical documentation and application of the coding guidelines. Clinically validates diagnoses in question. Manages the complete appeals process through all levels of appeal according to payor contract.

Responsibilities

• Initiate and follow through for all RAC and Third Party Payor denials at every level; reviews all denials with direct report for plan/strategy for appeal.
• Must be able to meet or exceed appeal deadline completion times.
• Involve appropriate physicians in the appeal process, including preparation for ALJ and DRA.
• Follow up on Third Party Payor responses to all appeals as appropriate and update RAC and Third Party Payor focus studies, as well as Epic revenue cycle with attention to detail.
• Communicate denial issues with site HIM/CDIP Department and patient accounts.
• Continuously evaluate the quality of clinical documentation to identify incomplete or inconsistent documentation, clinical validation for inpatient diagnoses that impact the code selection, resulting DRG, and payment.
• Apply working knowledge of AHA Coding Clinics and encoder to correct coding and re-drop bill.
• Communicate with physician advisor or attending physician verbally or through written methodology to validate diagnosis in question and support appeal.
• Provide feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participate in the planning and development of educational programs.
• Participate in education programs to maintain up-to-date coding skills.

Requirements

• Bachelor of Science in Nursing, OR NP or PA license.
• Current NYS License.
• Certification: CCDS required.
• Five years of clinical experience in an acute hospital setting.
• Minimum of 2 years of inpatient CDI experience.
• Proficiency in ICD-10-CM and PCS Official Guidelines for Coding and Reporting.

Skills

• Proficient computer skills for Windows Microsoft Office Applications (Word, Excel, PowerPoint).
• Self-motivated, self-directed, and able to work independently with minimal supervision.
• Multitasking, excellent communication, and critical thinking skills.

Pay

Salary range: USD $130,000.00 - USD $170,000.00 per year. This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies, and experience.

Benefits

• Generous benefits packages.
• Generous tuition assistance.
• Defined benefit pension plan.
• Culture that supports professional and educational growth.