Role Description The Clinical Documentation Integrity DRG Downgrade Specialist is responsible for reviewing, analyzing, and responding to payer‑initiated DRG downgrades. The role ensures accurate DRG assignment, protects revenue integrity, and supports compliant documentation practices through detailed review, appeal preparation, and performance tracking. The Specialist serves as an effective change agent, acting as a resource and educator for providers and interdisciplinary care teams to improve documentation quality, coding accuracy, and audit readiness. - Analyze payer DRG downgrade notifications to determine validity based on ICD‑10‑CM/PCS coding guidelines, clinical indicators, and documentation sufficiency. - Conduct comprehensive medical record reviews to validate principal diagnosis, secondary diagnoses, procedures, MCC/CC capture, and DRG assignment accuracy. - Write clear, persuasive, evidence‑based appeal letters that incorporate clinical rationale, coding guidelines, and regulatory references to support the original DRG. - Submit appeals within required timelines and track each case through all stages of the appeal lifecycle, including initial review, reconsideration, and final determination. - Maintain detailed logs of downgrade cases, outcomes, appeal success rates, and turnaround times to support throughput monitoring, trend analysis, and performance reporting. - Identify patterns in payer downgrades and escalate systemic issues or documentation vulnerabilities to leadership. - Collaborate with internal teams and providers to clarify ambiguous documentation and ensure clinical specificity. - Identify documentation gaps or inconsistencies and provide targeted feedback to improve provider documentation practices. - Participate in internal audits, retrospective reviews, and quality assurance processes related to DRG validation, coding accuracy, and documentation completeness. - Assist in developing or refining documentation templates, provider education materials, and query processes to support ongoing CDI improvement. - Ensure all coding and documentation practices align with CMS regulations, AHA Coding Clinic guidance, and organizational compliance policies. - Stay current on payer audit trends, regulatory updates, DRG methodology changes, and emerging risk areas that may impact DRG assignment or audit outcomes. - Support compliance initiatives by identifying potential vulnerabilities and recommending corrective actions or process improvements. - Partner with internal teams to resolve complex DRG issues and ensure alignment across departments. - Participate in provider education sessions, meetings, and case reviews to promote accurate documentation and DRG integrity. - Communicate effectively with leadership regarding trends, risks, and opportunities for improvement in documentation and coding practices. - Serve as a subject‑matter expert for DRG downgrade processes, providing guidance and support to internal teams. - Other duties as assigned. - Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. - Understand and comply with Information Security and HIPAA policies and procedures at all times. - Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties. Qualifications - Bachelor’s degree in Nursing required. - Minimum of 3 years of experience in clinical documentation improvement role - adult acute care experience in medical/surgical, critical care, emergency, and/or PACU setting. - RN, CCDS and/or CDIP with CCS (CCS, CIC) certification required. - Demonstrated inpatient coding experience in an acute care setting. - Prior experience managing DRG downgrades, including appeal letter development. - Deep knowledge of ICD-10-CM/PCS, ICD-10 Official Coding Guidelines and both MS and APR DRG Reimbursement Systems. - Ability to interpret complex clinical documentation across multiple specialties. - Proficiency with EMR systems, encoder tools (e.g., 3M, Optum) and CDI workflow and reporting tools. - Proficiency in Microsoft Office Suite. - Strong interpersonal skills, ability to communicate well at all levels of the organization. - Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses. - High level of integrity and dependability with a strong sense of urgency and results oriented. - Excellent written and verbal communication skills required. Requirements - Ability to work outside of normal business hours as needed. - Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes. Physical Demands - While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Mental Demands - The employee must be able to follow directions, collaborate with others, and handle stress. Work Environment - The noise level in the work environment is usually minimal.

Role Description This position is a field-based position based in Youngstown, OH in the Cardiac Rhythm Management division. As a global leader in Cardiac Rhythm Technologies, we focus on innovative technologies that can improve the way doctors treat people with heart arrhythmias or irregular heartbeats. Under general direction, the CRM Product Support Specialist provides comprehensive engineering, sales, educational, and technical support. This role responds to field inquiries from physicians, healthcare professionals, patients, and field sales staff regarding CRM (Cardiac Rhythm Management) products. Key Responsibilities: - Clinical Interface: Acts as a senior clinical interface between the medical community and the business. - Relationship Building: Demonstrates the ability to build and sustain credible business relationships with customers and share product expertise accordingly. - Comprehensive Support: Provides engineering, sales, education, and clinical support in response to field inquiries on an as-needed basis. Demonstrates a thorough command of all CRM products, related product and technical knowledge, trends, and players while providing regional case coverage. - Training and Education: Develops, leads, and/or facilitates training sessions and other programs on CRM products for healthcare professionals. - Sales Support: Provides additional back-up support to Cardiac Rhythm Team in the following areas: - Sales support - Regional training seminars - Clinical studies/data collection - Trouble Shooting - New product in-service training to physicians, nurses and sales representatives - Mentors and provides leadership for less experienced Clinical Specialists. - Continuously develops engineering, sales and technical skills relative to the overall Arrhythmia Management strategy, including learning opportunities via Sr. Sales personnel and management. Qualifications - Bachelor’s degree in Bio-Medical Engineering, related field or equivalent healthcare experience. - 4+ years of related experience or a program certification from an accredited cardiac training program. - Must have certifications in CRM products. - Demonstrated knowledge of cardiology, electro-physiology, or cardiac electro-physiology procedures. - Familiarity with cath lab and operating room procedures and protocol. - Demonstrate advanced knowledge of cardiac pacing systems. - Must apply engineering skills and abilities to interpret and solve complex clinical problems. - Must possess strong written and verbal communication skills, along with excellent interpersonal, presentation, analytical, and organizational abilities. - Must be detail-oriented and capable of working independently. - Must be able to collaborate effectively with engineers, technical specialists, vendors, and customers to achieve assigned goals. - Must have extensive personal computer skills, including experience with Microsoft Office or equivalent software. Requirements - Must be capable of managing multiple assignments simultaneously and efficiently. Benefits - Career development with an international company where you can grow the career you dream of. - Employees can qualify for free medical coverage in our Health Investment Plan (HIP) PPO medical plan in the next calendar year. - An excellent retirement savings plan with a high employer contribution. - Tuition reimbursement, the Freedom 2 Save student debt program, and FreeU education benefit - an affordable and convenient path to getting a bachelor’s degree. - A company recognized as a great place to work in dozens of countries worldwide and named one of the most admired companies in the world by Fortune. - A company that is recognized as one of the best big companies to work for as well as the best place to work for diversity, working mothers, female executives, and scientists.

Role Description As a Utilization Management Clinical Dental Processor, you will leverage your professional judgment to evaluate service requests and determine their appropriateness, assessing the necessity of treatments prior to provision. You will apply national clinical criteria and maintain up-to-date knowledge of relevant laws, regulations, and organizational policies, utilizing clinical judgment in your evaluations. To meet our client standards, you will be required to complete 13 to 18 cases per hour, ensuring our contractual obligations are fulfilled. Additionally, you will complete clinical scripts, review patient histories, and import supporting documentation into our internal system. Work hours will be determined by your manager and may vary based on location, department needs, and workflow. Mandatory overtime may be required during peak seasons. - Conducts reviews of prior authorizations by providers. - Determines cases of recommended treatment in accordance with Avesis UM procedural guidelines or refers the case to Clinical Director or consultant for professional review of clinical denials. - Ensures that the right systems, processes, and measurements are in place to assist with accurate clinical determinations. - Understands and upholds Avesis’ policies and obligations relative to the UM reviews required by each client contract. - Documents approval decisions for treatment in accordance with prescribed UM department procedural guidance. - Provides recommendations on department policies, objectives, and initiatives. - Maintains a daily level of productivity in accordance with departmental requirements for production and quality standards. - Maintains effective intradepartmental communications through sharing of plans and actively participates in routine departmental meetings. - Other duties as assigned. Qualifications - High School Diploma/GED. - Dental Assistant or Dental Hygienist required. - Dental Assistant certificate or 2 years of chair side assisting. - 1-2 years of experience reviewing dental x-rays, models, photos, and patient charts required. - Proficiency with Microsoft Office and other Windows-based applications. - Strong reading, writing, and professional communication skills. - Ability to manage multiple tasks and prioritize work. - Adaptability to handle multiple and changing priorities. - Effective time management and organizational skills. - Access to reliable internet connection (25 MBPS upload/10 MBPS download speed) and an appropriate workspace are essential for success in this remote role. Requirements - X-Ray certification is highly preferred. - Knowledge of Medicare, Medicaid, or commercial insurance. - Experience with HCPCS, CPT, CDT, and ICD-10 coding. Benefits - Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way. - Competitive compensation package. - Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period. - Life and disability insurance. - A great 401(k) with company match. - Tuition assistance, paid parental leave and backup family care. - Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent. - Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best. - Employee Resource Groups that advocate for inclusion and diversity in all that we do. - Social responsibility in all aspects of our work.

Role Description This position will be a part of our Provider Clinical Service Desk, as an agent primarily handling inbound customer calls. This is a call center environment in which we support our customers 24x7x365. - All candidates are required to be shift flexible. Shift work is required including nights, weekends, and/or holidays. - Account specific training is conducted during day shift hours, regardless of assigned shift. - Respond to incoming service desk calls from healthcare customers regarding the clinical aspects of various clinical applications such as Epic, Cerner, McKesson, and Meditech. - Incidents may include, but are not limited to workflow issues, application errors, user access, and functionality. - Track and document the appropriate comments, and close or escalate the incident tickets and related issues in a timely manner. - Responsible for driving resolution of incidents on a 24/7 desk. - Read text on computer screens for the duration of the shift. - Remain at designated workspace and in the phone queue for an 8 to 10-hour period with scheduled breaks. - Ensure a quiet, private workspace with high speed, wired internet. - Travel up to 10% of the time, if required. - Lift up to 25 lbs. if needed for equipment setup. - Have a working cell phone for manager communication and Two-Factor Authentication. Qualifications - Minimum of 4 years of service desk / helpdesk experience or equivalent combination of education and technical troubleshooting experience (i.e., 2 years of work experience and 2 years of technical education). - Minimum of 1 year of technical troubleshooting experience. - High school diploma or equivalent required. Requirements - Experience in a call center environment. - Demonstrate a service philosophy in all interactions with clinicians and colleagues. - Effective communication and interpersonal skills. - Proficient typing and English language skills (both verbally and in writing). - Strong listening capabilities to fully understand caller’s needs / requests. - Exceptional ability to work optimally in a fast-paced environment. Benefits - This position is only available to those interested in direct staff employment opportunities with NTT DATA, Inc., or its subsidiaries. - We offer a full comprehensive benefits package that starts from your first day of employment.