Appeals and Denials Specialist

The Appeals and Denials Specialist is responsible for triaging and writing DRG downgrades and clinical validation appeal letters for multiple clients. The Appeals and Denials Specialist will ensure appropriate action is taken within appeal deadlines. This position collaborates with the Appeals and Denials team and other departments as needed.

Performs review of the medical record including documentation, reports, flowsheets, and test results, applying evidence-based criteria related to DRG and clinical validation denials Creates appeal letters utilizing the relevant information from the medical record; supported by current clinical standards and facility guidelines, evidence-based medicine, professionally recognized standards of health care, and ICD-10-CM/PCS Official Coding Guidelines Is flexible, able to navigate multiple EHRs and other databases used by Accuity or the client, performs reviews, and submits letters of appeal per the client specific workflows Able to prioritize cases to meet appeal deadlines Detail-oriented Collaborates with Accuity Physician and Accuity CDI in appropriately identified clinical denials requiring communication to the Accuity clinical review teams Maintains clinical expertise and trends in healthcare, reimbursement methodologies and specialty areas by participating in professional organizations, seminars, and educational programs Performs miscellaneous job-related duties as assigned