Role Description
The Appeals and Denials Specialist is responsible for reviewing inpatient medical records and preparing evidence-based appeal letters for Diagnosis-Related Group (DRG) downgrades and clinical validation denials across multiple client engagements. This role applies clinical expertise, coding guidelines, reimbursement knowledge, and industry best practices to support successful appeal outcomes while ensuring all appeals are completed within client-specific deadlines. The Appeals and Denials Specialist collaborates with physicians, Clinical Documentation Integrity (CDI) professionals, and cross-functional teams to ensure accurate clinical representation and high-quality appeal documentation.
Responsibilities
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Review inpatient medical records, including physician documentation, diagnostic reports, laboratory results, flowsheets, and ancillary clinical documentation to evaluate DRG downgrade and clinical validation denials.
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Analyze denials using evidence-based clinical practice, payer criteria, ICD-10-CM/PCS Official Coding Guidelines, facility-specific policies, and professionally recognized standards of care.
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Prepare clear, concise, and well-supported appeal letters utilizing relevant clinical documentation, current medical literature, reimbursement guidance, and regulatory requirements.
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Prioritize assigned cases to ensure all appeal deadlines and client service level agreements are met.
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Navigate multiple electronic health record (EHR) platforms and client systems to complete medical record reviews and submit appeal documentation according to established client workflows.
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Collaborate with Accuity physicians, CDI specialists, coding professionals, and operational teams to resolve complex DRG downgrade and clinical validation denials.
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Communicate identified clinical issues requiring physician review or additional clinical validation to appropriate internal stakeholders.
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Foster collaborative working relationships with internal teams to promote consistent, high-quality appeal outcomes.
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Ensure appeal documentation complies with applicable coding guidelines, reimbursement methodologies, payer requirements, and client expectations.
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Maintain accuracy, consistency, and quality throughout the appeal review and documentation process.
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Protect the confidentiality of patient information and adhere to all HIPAA and organizational compliance requirements.
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Maintain current knowledge of clinical documentation integrity, reimbursement methodologies, coding updates, payer trends, and specialty-specific clinical practices.
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Participate in continuing education, professional organizations, seminars, and other development opportunities to maintain subject matter expertise.
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Perform additional duties and special projects, as assigned in support of departmental and organizational objectives.
Qualifications
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Associate or Bachelor's degree in Nursing or equivalent clinical healthcare education required.
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Current licensure or credential in a clinical healthcare discipline such as RN, NP, PA, or MD preferred.
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One or more of the following credentials required or preferred:
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Registered Nurse (RN)
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Bachelor of Science in Nursing (BSN)
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Certified Clinical Documentation Specialist (CCDS)
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Certified Documentation Integrity Practitioner (CDIP)
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Medical Doctor (MD)
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Minimum of three (3) years of Clinical Documentation Integrity (CDI) experience or equivalent experience managing inpatient DRG downgrade and clinical validation denials.
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Inpatient clinical experience required.
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Demonstrated knowledge of ICD-10-CM and ICD-10-PCS Official Coding Guidelines.
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Experience with revenue cycle operations, reimbursement methodologies, and coding services.
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Experience utilizing electronic health record (EHR) systems and health information technologies.
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Proficiency with Microsoft Office applications, including Word, Excel, and PowerPoint.
Requirements
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Strong analytical and critical thinking skills with the ability to interpret complex clinical documentation.
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Excellent written communication skills with the ability to develop clear, evidence-based appeal letters.
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Strong interpersonal skills with the ability to build effective working relationships across clinical and operational teams.
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Exceptional attention to detail and commitment to producing accurate, high-quality work.
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Effective organization and time management skills with the ability to prioritize competing deadlines.
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Demonstrated accountability and sound professional judgment.
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Self-motivated with the ability to work independently in a fully remote environment.
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Adaptable and comfortable navigating multiple EHR platforms and technology systems.
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Customer-focused with a commitment to delivering high-quality client service.
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Commitment to continuous learning and maintaining current clinical and reimbursement knowledge.
Additional Requirements
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Physical Requirements: The requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations. Unless otherwise indicated, Accuity positions require interaction with people and technology while either sitting or standing. Employees must be able to communicate via phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. Physical effort and exposure to physical risk are limited to that of an office role/environment.
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Position and Employment Statement: While this job description is intended to be an accurate reflection 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. All positions at Accuity Delivery Systems, LLC, are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.
