Clinical Denial Specialist - Diagnosis Related Grouping (DRG)

About the Role

Day-to-day responsibilities will include managing the timely review of and response to enterprise hospital billing audits, preparing and submitting detailed clinical appeals, and negotiating with external auditors. The specialist will also apply regulatory knowledge, including CMS guidelines, coding rules, and clinical standards, to support the organization's position. Given the complexity of the role, the ability to work independently with minimal supervision is crucial, while also maintaining current clinical and coding knowledge and representing the organization effectively in communications with payers and external auditors.

WVU Medicine is committed to providing high-quality patient care, and this role is integral to that mission. The successful candidate will be part of a team dedicated to excellence and continuous improvement, with opportunities for professional growth and development.

What You Will Do

• Manage the timely review of and response to enterprise hospital billing audits received electronically and via postal mail.
• Conduct comprehensive reviews of patient medical records to validate clinical relevance and assess DRG accuracy.
• Identify discrepancies between documentation and billed charges, preparing and submitting detailed clinical appeals as necessary.
• Negotiate with external auditors, applying regulatory knowledge to support the organization's position.
• Collaborate with clinical, coding, revenue cycle, and educational stakeholders to support ongoing process improvement.
• Develop educational materials and enhance organizational compliance and documentation quality.
• Work independently with minimal supervision, maintaining current clinical and coding knowledge.
• Represent the organization effectively in communications with payers and external auditors.
• Participate in feedback loops to ensure continuous improvement in clinical denial management.

What We Are Looking For

• Associate degree in healthcare administration, Nursing, Health Information Management, or a related field, and five years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle.
• Alternatively, a Bachelor’s degree in healthcare administration, Nursing, Health Information Management, or a related field, and three years of experience in the aforementioned areas.
• Certification or License in one of the following: Current Registered Nurse license, current multi-state Registered Nurse license, Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), Certified Coding Specialist (CCS), or Certified Inpatient Coder (CIC).
• Strong technology skills, including but not limited to Excel.
• Ability to adjust to new systems and technologies as needed.

Nice to Have

• Two years of hospital appeals/denials, HIM, or compliance experience.
• Seven years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle setting.
• Strong understanding of Epic, Solventum, Wellington, and MSDRG/DRG groupers.

Benefits and Perks

• Competitive compensation package.
• Opportunities for professional growth and development.
• Comprehensive health insurance.
• Generous paid time off (PTO) policy.
• Remote work stipend.
• Access to cutting-edge technology and systems.
• Collaborative and dynamic work environment.

• Ensure your resume and cover letter are tailored to the Clinical Denial Specialist role, highlighting relevant experience in hospital billing, CDI, or inpatient coding.
• Develop a strong understanding of DRG and coding rules, as well as regulatory knowledge including CMS guidelines and clinical standards.
• Prepare examples of how you have managed complex billing audits and appeals, and be ready to discuss your negotiation strategies with external auditors.
• Familiarize yourself with the technology and systems used by WVU Medicine, such as Excel and Epic, to demonstrate your ability to adjust to new tools.
• Research the company culture and values to understand how you can contribute to the organization's mission and goals.
• Be prepared to discuss your experience working independently and as part of a team, and how you stay current with changing regulatory guidelines and coding rules.