DRG Appeals Specialist

DRG Appeals Specialist

Office Location: Newtown Square, PA with remote opportunities available

Commitment: Full-Time

About Versalus Health

Versalus Health is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. Versalus Health has expanded its product offering to include DRG Revenue Integrity services. Versalus Health provides programmatic solutions for DRG compliance and revenue integrity by leveraging advanced analytics and DRG auditing and clinical expertise. Versalus offers outstanding growth opportunities, a competitive salary and benefits package including bonuses based on individual and company performance, and reimbursement for continuing education and association dues. Versalus has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Description:

The DRG Appeals Specialist performs reviews of inpatient DRG payer denials on behalf of our hospital client partners. Responsibilities include reviewing denial letters, determination and data entry of audit recommendations, and responsibility for professional and effective appeal responses that are submitted timely under payer timeframes.

Job Responsibilities:

• Performs comprehensive reviews of inpatient medical records to validate the MS/APR DRGs assigned for Medicare, Commercial, and Third-Party paid claims.
• Validates that all ICD-10-CM/PCS, discharge disposition codes, and Hospital Acquired Condition (HAC), Present on Admission (POA) indicators impacting payment are documented, clinically supported, and assigned following Official Coding Guidelines, compliant query practices and current clinical validation criteria.
• Utilizes audit reference tools and applications (e.g., proprietary denials management application, TruCode, and 3M encoder and grouper software and references).
• Reviews denial letters rationale and formulates custom appeal response letters utilizing strong critical thinking skills to independently access cases for strengths and weaknesses within the appeals spectrum. Constructs and documents a brief and fact-based case utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine, and official coding guidelines. Applies strong writing and grammar skills to formulate professional appeal letters that clearly support each appeal argument.
• Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures.
• Maintains subject matter expertise in clinical validation criteria and practices, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies.
• Attends continuing education workshops, webinars, etc., for coding and documentation integrity and compliance.
• Other responsibilities as assigned. Duties may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing.

Required Education/Experience:

• RN/RHIA/RHIT required.
• CCS will be required after one year of employment. (Assistance is available for preparation.)
• CDIP or CCDS is highly preferred.
• Certifications and/or professional license must be maintained as a condition of employment.
• A minimum of 5 years of experience in any of the following roles:
• Inpatient coding quality assurance
• DRG validation
• DRG appeal
• Clinical Documentation Integrity (CDI) as a Clinical Documentation Specialist (CDS), Educator, or Manager

Skills:

• Extensive Inpatient Coding Skills. Possess regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS/APR DRG payment methodologies, including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
• Clinical Validation Skills. Demonstrate the ability to identify, apply, and validate the use of current industry standard clinical indicators, risk factors and treatment protocols used in clinical validation of payment impacting code assignment. Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, disease assessment, management and treatment is required.
• Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes, and evaluates information gathered from, or generated by observation, experience, reflection, reasoning, or communication as a guide to validate audit results and correct, as necessary.
• Adaptability. Maintains effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures.
• Initiative. Is proactive and self-directed. Show initiative and responsibility in taking the necessary steps towards problem resolution. Is self-sufficient and does not need to rely on others to complete a job.
• Vivacity. Consistently maintains high levels of activity or productivity sustained over long working hours when necessary; operates with vigor, effectiveness, and determination.
• Performance. Meets or exceeds both production and quality expectations while performing complex medical record audits. Able to execute under pressure of time constraints and while managing multiple responsibilities.
• Planning and Organization. Proactively prioritizes initiatives, effectively manages resources and can multi-task. Actively manages their work assignments and seeks additional tasks when appropriate.
• Communication Skills. Communicates clearly, proactively, and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise rationales in support of findings and successfully crafts appeal letters with precise logic.
• Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail, identifies aberrant code assignment, mines medical records for all relevant and supporting evidence, intuitively understands appeal strategies and conscientiously follows all steps in the audit and appeals process. Committed to life-long learning.
• PC Skills. Demonstrates proficiency in Microsoft Office and Teams, WebEx, VPN access, navigating various EHRs, and ability to problem solve Internet connectivity issues.

Benefits

• Enjoy work-life balance with a predictable schedule
• Compensation includes salary plus bonus opportunities
• Medical, Dental, Vision coverage, 401K
• Holidays, paid time off, short term and long-term disability insurance, and life insurance
• Reimbursement for continuing education and association dues

Physical Requirements:

May be expected to sit at a desk for long hours. Must have a private and secure space to work, including a secure Internet connection. Repetitive movement of hands and fingers – typing and/or writing. Occasional standing, walking, stooping, kneeling, or crouching. Ability to reach with hands and arms, talk, and hear. Exert up to 20 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

Versalus Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics, or any other basis forbidden under federal, state, or local law.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Health insurance
• Paid time off
• Vision insurance

Supplemental Pay:

• Bonus pay

License/Certification:

• RN/RHIA/RHIT (Preferred)

Work Location:

• Fully Remote

Work Location: Remote