DRG Appeals Specialist

19 minutes ago

Pasig, National Capital Region, Philippines Health Business Solutions Full time

Key Responsibilities:

  • Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.

  • Analyze payer denials involving: o DRG downgrades o Removal of CC/MCC o Clinical validation denials o Coding validation disputes.

  • Prepare clear, concise, and compliant DRG appeal letters supported by:

o ICD-10-CM/PCS Official Guidelines

o UHDDS reporting requirements

o CMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)

  • Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards

  • Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases

  • Ensure timely filing of appeals in accordance with payer and client deadlines

  • Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time

  • Participate in quality audits, peer reviews, and continuous process improvement initiatives

  • Maintain strict compliance with HIPAA and data privacy regulations.

Required Qualifications:

  • Inpatient Coding Experience (required)

  • Strong working knowledge of:

o ICD-10-CM and ICD-10-PCS

o MS-DRG and APR-DRG systems

o CC/MCC logic and DRG impact

  • Demonstrated experience handling DRG appeals or inpatient coding denials

  • Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.

  • Excellent written communication skills with the ability to cite official coding and clinical references.

  • High attention to detail, critical thinking, and strong analytical skills.

  • Ability to work independently while meeting productivity and quality benchmarks

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