Remote DRG Appeals RN

Job Overview

  • Specialty License RN
  • State License(s) Nationwide

DRG Appeals Nurse

Full Time/Part Time l Remote l Permanent

Purpose:

The Clinical Appeals Review Nurse reviews and analyzes denied/downgraded MS-DRG and APR-DRG and APC accounts received from all types of payers (e.g., Medicare, Commercial, and Third Party). Utilizing clinical and coding expertise, the Nurse will render determination on whether the denied/downgraded account is appealable based on the standards of each client. After review of the denial and medical record, the Clinical Appeals Review Nurse will provide either a reasoned explanation why no appeal can be written, or a detailed appeal letter based on current coding and regulatory guidelines and clinical criteria. In either case the Nurse will then track and trend MRI defined denial root causes for each specific denial.
Essential Job Functions:
Complete the following functions in accordance with Managed Resources policies:

  • Perform efficient analysis of denied claims, pinpointing reason for denial and potential for success of appeal including correct allocation of diagnostic and procedural codes under:
  • ICD-10 Official Coding Guidelines and ICD-10 Procedural Coding Guidelines
  • 3M APR-DRG Classification System
  • CPT
  • HCPCS
  • Revenue Code
  • All associated authorities such as CMS regulations, statutes, and associated authorities such as AHA Coding Clinics and CPT Assistant
  • When the decision is made to appeal:
  • Write clear and concise grammatically correct appeals letter in MRI format and to MRI quality standards
  • Be aware of the level of appeal, level of future appeals available and write according to the level of appeal
  • Utilize current applicable clinical, legal, and coding standards
  • Understand and strictly comply with time deadlines; write appeals in an efficient and timely manner
  • Provide a reasoned root cause analysis and summary review for all clients within MRI standard
  • At all time observe all HIPAA standards
  • Obtain and maintain client computer accesses
  • Participate in preparation of clear and concise audit report, as needed
  • Stay current in clinical, coding, and appeal writing areas and comply with MRI quality recommendations to maintain efficient and effective processes
  • Identify coding and clinical documentation issues and provide proactive recommendations through manager to clients
  • Identify problem account and seek review or return to client through manager, as appropriate
  • Clearly and concisely update patient account record to identify actions taken on account
  • Responsible to work through manager to liase with third party payer and agencies regarding appeals to ensure optimal reimbursement and resolve billing issues, contract misrepresentations and payment discrepancies

Ideal candidate will possess the following:

  • Registered Nurse (RN) License is required
  • CCS, CPC, CCDS, or RHIT Certification is required
  • Graduate of an accredited College or University, BSN is preferred
  • 5+ years of clinical experience in Hospital inpatient and outpatient departments
  • 3+ years of clinical appeals/denials writing experience
  • Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG and APC medical records and accounts received from payers (e.g., Medicare, Commercial, and Third Party)
  • Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. (3M, Nuance, Epic, etc)
  • Excellent verbal and written communication skills
  • Excellent computer (Word, Excel, Skype, Dual Screens, etc.) skills
  • Excellent organizational and time management skills with a strong focus on detail and the ability to work remotely in an environment where HIPAA regulations can be enforced

Preferred:

  • 2+ years of medical coding experience for inpatient and outpatient
  • 2+ years of Clinical Documentation Improvement (CDI) experience

Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO

Job Types: Full-time, Part-time

Pay: $38.00 – $42.00 per hour

Benefits:

  • 401(k)
  • 401(k) Matching
  • Dental Insurance
  • Flexible Schedule
  • Health Insurance
  • Life Insurance
  • Paid Time Off
  • Vision Insurance

Schedule:

  • Day shift
  • Monday to Friday
  • Night Shift
  • Weekends

Experience:

  • DRG Appeals Writing (Provider Side): 3 years (Required)
  • Clinical Nursing (Acute Care), Multi-Specialty: 7 years (Required)

Education:

  • Bachelor’s (Required)

License:

  • Registered Nurse (RN) (Required)
  • Coder Certification (CPC, CCS, CDIP, CCDS, etc.) (Required)

Work Location:

  • Fully Remote

Hours per week:

  • 20-29
  • 30-39

Benefit Conditions:

  • Waiting period may apply
  • Only full-time employees eligible

Work Remotely:

  • Yes