Clinical DRG Appeals Review Nurse


Industry: Nurse - Compliance/Appeals Job Number: 2697

Job Description


Part-Time & Full Time Available | Remote| Permanent

The Clinical Appeals Review Nurse, CCS reviews and analyzes denied/downgraded MS-DRG and APR-DRG accounts received from 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. The Clinical Appeals Review Nurse, CCS will provide an appeal letter based on current coding guidelines and clinical criteria, as well las track and trend denial root causes for the specific coding denials.

Managed Resources is a leading consulting group assisting healthcare organizations nationwide in optimizing its revenue cycle management through review, recovery and educational programs.

Please read the below description and apply if you meet the requirements and would like to hear more about this opportunity with Managed Resources.

  • Write clear and concise letters, handle necessary technical vocabulary, and organize difficult or complex information in an understandable and efficient manner
  • Prepare clear and concise audit reports
  • Serves as a liaison with third party payer and agencies regarding appeals to ensure optimal reimbursement and any other billing or payment issues and ensuring issues are resolved
  • Develops recommendations to maintain efficient and effective processes
  • Identifies coding and clinical documentation issues and provides proactive recommendations to clients
  • Identifies problem accounts and escalates as appropriate
  • Updates patient account record to identify actions taken on account
  • Responsible for favorable resolution of third-party payment denials, adverse determinations, medical necessity denials, payment discrepancies, and contract misinterpretations
  • Review whether DRG’ s are assigned correctly and if all diagnosis and procedure codes are identified and documented

  • Registered Nurse (RN) License is required
  • CCS Certification through AHIMA is required
  • CDIP and/or CCDS is highly preferred
  • Graduate of an accredited College or University, BSN is preferred


  • 5+ years of clinical experience in Hospital inpatient and outpatient departments
  • 2+ years of clinical appeals/denials writing experience
  • Experience reviewing and analyzing denied/downgraded MS-DRG and APR-DRG accounts received from payers (e.g., Medicare, Commercial, and Third Party)
  • Experience with Interqual and Milliman Care Guidelines (MCG) along with payer specific medical guidelines and how to apply them in an appeal
  • Experience in a variety of Electronic Medical Records (EMR) Systems, i.e. 3M, Nuance
  • Excellent verbal and written communication skills
  • Excellent organizational skills with a strong focus on detail

  • 2+ years of case management experience
  • 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

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