DRG and Clinical Appeals Specialist

This is a Fully Remote Job
About Our Client:
This organization operates within the healthcare revenue cycle management sector, addressing challenges related to clinical documentation, coding accuracy, and denial management. It focuses on improving the integrity of revenue processes through clinical validation, appeals, and coding compliance to optimize reimbursement and reduce denials.
About the Opportunity:
The DRG AND CLINICAL APPEALS SPECIALIST plays a critical role in managing denied claims related to diagnosis-related group (DRG) downgrades, clinical validation, and coding denials. This position supports multiple revenue cycle functions including appeals preparation, clinical validation, audits, and denial prevention, contributing directly to revenue recovery and operational efficiency.
Responsibilities:
Review denied claims involving DRG downgrades, clinical validation, and coding denials
Analyze medical records and related clinical data to identify appeal opportunities
Draft evidence-based appeal letters aligned with clinical and coding guidelines
Prepare first and second-level appeals for commercial, Medicare, Medicare Advantage, and Medicaid payers
Defend clinical validity of diagnoses commonly challenged by payers
Validate coding accuracy, DRG assignment, and reimbursement decisions
Research and apply clinical literature and regulatory guidance to support appeals
Track appeal outcomes, revenue recovery, and denial trends for improvement
Participate in client education on denial prevention, documentation, and coding
Conduct DRG audits, coding compliance reviews, and clinical validation during low appeals volume
Requirements:
Current RN license or professional coding credential
Bachelor’s degree in nursing, Health Information Management, or related field preferred
Minimum five years' experience in Clinical Documentation Integrity, inpatient coding, denials management, or related revenue cycle operations
Preferred three years' experience writing successful payer appeals
Experience with Medicare, Medicaid, RAC, and commercial insurance denials
Familiarity with electronic health records and encoder applications
Preferred proficiency with 3M, Epic, Cerner, TruCode, Optum, or similar CDI/coding technologies
Preferred certifications: CCDS, CDIP, CCS, RHIA, RHIT, CPC, or CRC
Advanced knowledge of ICD-10-CM/PCS, MS-DRG/APR-DRG methodologies, and reimbursement systems
Strong clinical documentation integrity and clinical validation skills
Excellent analytical, critical-thinking, and written communication abilities
Understanding of CMS regulations, payer audit methods, and Coding Clinic guidance
Ability to prioritize tasks and adapt across multiple revenue cycle functions
Pay Range and Compensation Package:
$95,000–$135,000
Benefits & Perks:
Health insurance
Vision insurance
Dental insurance
Retirement plan
Paid time off
Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.
Note:
TalentHop is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.

Work arrangement
Yes