DRG Downgrade Appeals Specialist

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.

We are always looking for people inspired to help us in our mission. If you are someone who wants to change the lives of patients, drive success for our partners and be part of a team driven to improve care, we may have your next opportunity.

POSITION SUMMARY:

This position involves conducting a thorough review of the medical record and drafting appeal letters, preparing for peer-to-peer and/or ALJ hearings and discussing cases with clinical and coding teams. This position will support Lifepoint's increased focus on DRG downgrades (payor reimbursement changes due to a change in the coding submitted on the billing claim form).  This position will enable the coding and CDI teams to bridge communication and coordination gaps driven from use of different systems and terminologies.  This role will serve as a navigator for the process flow and denial appeals of complex clinical coding cases.

ESSENTIAL FUNCTIONS: 

• Responsible for conducting medial record reviews and responding to insurance DRG downgrades. Writes concise, factual letters and provides medical record documentation to support appeal.  Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Responsible for the denials process, including subsequent appeal letters.
• Assures appropriate action is taken within appeal time frames to address DRG downgrade.
• Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome.
• On a monthly basis presents identified denial trends and patterns and creates education on root cases and preventable measures.
• Utilizes appropriate applications to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals.
• Reviews and has knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations, National Coverage Determinations, Policy Bulletins, etc.
• Assists with continuous quality improvement of the established appeals process.
• Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.
• Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors.
• Other related job tasks or responsibilities as assigned.

Education: 

• Associate degree in health-related field required. 

Required Experience:

• 2 years of experience preparing appeals for DRG downgrades or writing clinical denials on behalf of payers.  
• Strong knowledge of medicine and pathophysiology with understanding of clinical criteria and treatment of medical diagnoses.

Preferred Experience:  

• 3 years of appeals, coding, or CDI experience; CPC, CCS or equivalent Coding Certification; Certification in Clinical Documentation Improvement (CCDS or CDIP)

Certifications:

• Nurse, medical school graduate, physician assistant (RN, NP, PA, MD, DO, MBBS) OR an RHIA/RHIT

Licenses:

• Current, unrestricted RN license (for RN applicants)