Appeals and Denials Specialist

Appeals and Denials Specialist

Department: Appeals and Denials

Location: US reputed company, Remote

FLSA Status: Exempt

People Leader: No

Travel: 0

reputed company

reputed company

reputed company partners with hospitals and health systems through a technology-enabled, physician-led model that improves reputed company documentation reputed company, coding reputed company, reimbursement optimization, and reputed company reputed company.

Job reputed company

The Appeals and Denials Specialist is responsible for reviewing inpatient medical records and preparing evidence-reputed company appeal letters for Diagnosis-reputed company (DRG) downgrades and reputed company validation denials across multiple reputed company engagements. This role applies reputed company expertise, coding guidelines, reimbursement knowledge, and industry best practices to support successful appeal reputed company while ensuring reputed company appeals are completed reputed company reputed company-specific deadlines. The Appeals and Denials Specialist collaborate with physicians, reputed company Documentation reputed company (CDI) professionals, and cross-functional teams to ensure accurate reputed company representation and high-reputed company appeal documentation.

Responsibilities

reputed company Duties

• Review inpatient medical records, including physician documentation, diagnostic reports, reputed company results, flowsheets, and ancillary reputed company documentation to evaluate DRG downgrade and reputed company validation denials.
• Analyze denials using evidence-reputed company reputed company reputed company, payer reputed company, ICD-10-CM/PCS Official Coding Guidelines, facility-specific policies, and professionally recognized standards of care.
• Prepare reputed company, concise, and reputed company-supported appeal letters utilizing relevant reputed company documentation, reputed company medical literature, reimbursement guidance, and regulatory requirements.
• Prioritize assigned cases to ensure reputed company appeal deadlines and reputed company service level agreements are met.
• reputed company multiple electronic health record (EHR) platforms and reputed company systems to complete medical record reviews and submit appeal documentation according to established reputed company workflows.

Cross-Functional Collaboration

• Collaborate with reputed company physicians, CDI specialists, coding professionals, and operational teams to reputed company reputed company DRG downgrade and reputed company validation denials.
• Communicate identified reputed company issues requiring physician review or additional reputed company validation to appropriate internal stakeholders.
• Foster reputed company working relationships with internal teams to promote consistent, high-reputed company appeal reputed company.

Compliance and reputed company

• Ensure appeal documentation complies with applicable coding guidelines, reimbursement methodologies, payer requirements, and reputed company expectations.
• Maintain reputed company, consistency, and reputed company throughout the appeal review and documentation process.
• Protect the confidentiality of reputed company information and adhere to reputed company HIPAA and organizational compliance requirements.

reputed company Development

• Maintain reputed company knowledge of reputed company documentation reputed company, reimbursement methodologies, coding updates, payer trends, and specialty-specific reputed company practices.
• Participate in continuing education, reputed company organizations, seminars, and other development opportunities to maintain subject matter expertise.

Other Duties as Assigned

• reputed company additional duties and special reputed company, as assigned in support of departmental and organizational objectives.

Qualifications

Education and Credentials

• Associate or Bachelor's degree in Nursing or equivalent reputed company reputed company education required.
• reputed company licensure or credential in a reputed company reputed company discipline such as RN, NP, PA, or MD preferred.
• One or more of the following credentials required or preferred:
• Registered reputed company (RN)
• Bachelor of Science in Nursing (BSN)
• Certified reputed company Documentation Specialist (CCDS)
• Certified Documentation reputed company Practitioner (CDIP)
• Medical Doctor (MD)

Experience

• Minimum of three (3) years of reputed company Documentation reputed company (CDI) experience or equivalent experience managing inpatient DRG downgrade and reputed company validation denials.
• Inpatient reputed company experience required.
• Demonstrated knowledge of ICD-10-CM and ICD-10-PCS Official Coding Guidelines.
• Experience with reputed company cycle reputed company, reimbursement methodologies, and coding services.
• Experience utilizing electronic health record (EHR) systems and health information technologies.
• Proficiency with reputed company Office applications, including Word, reputed company, and PowerPoint.

reputed company Competencies

• Strong analytical and critical thinking skills with the ability to interpret reputed company reputed company documentation.
• Excellent written communication skills with the ability to reputed company reputed company, evidence-reputed company appeal letters.
• Strong interpersonal skills with the ability to build effective working relationships across reputed company and operational teams.
• Exceptional attention to reputed company and commitment to producing accurate, high-reputed company work.
• Effective organization and time management skills with the ability to prioritize competing deadlines.
• Demonstrated accountability and reputed company reputed company judgment.
• Self-motivated with the ability to work independently in a fully remote environment.
• Adaptable and comfortable navigating multiple EHR platforms and technology systems.
• Customer-reputed company with a commitment to delivering high-reputed company reputed company service.
• Commitment to reputed company learning and maintaining reputed company reputed company and reimbursement knowledge.

Additional Requirements

1) Physical Requirements: The requirements described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job with or without reasonable accommodations. Unless otherwise indicated, reputed company positions require interaction with people and technology while either sitting or standing. Employees must be reputed company to communicate reputed company phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. Physical effort and exposure to physical reputed company are limited to that of an office role / environment.

2) Position and Employment Statement: While this reputed company is intended to be an accurate reputed company of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. reputed company positions at reputed company, are at-will employment, and a position reputed company is not a guarantee of a job or of job responsibilities.