Denial RN DRG Appeal Writer1 / HIM Coding

Work whereevery momentmatters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticutu2019s most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. _Position Summary:_ The Denial Specialist is responsible for reviewing, analyzing and appealing denials related to DRG (Diagnostic Related Group) downgrades. This role involves validating the coding and clinical accuracy, ensuring proper documentation and collaborating with other departments to address payer concerns. Key responsibilities include timely investigation of DRG downgrades, submitting appeals, coordinating follow-up actions and ensuring compliance with regulatory standards. The specialist also plays a critical role in preventing future downgrades by identifying trends and providing feedback to improve coding and clinical documentation practices. _Position Responsibilities:_ Key Areas of Responsibility Denial Resolution u00b7 Conduct a thorough review of medical records, coding and clinical documentation to validate or appeal payer denials. u00b7 Prepare, document and submit appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory requirements. u00b7 Work closely with the Clinical Documentation Improvement (CDI) and Coding teams to ensure accurate DRG assignment and enhance documentation practices that support appropriate reimbursement. u00b7 Ensure that all DRG denial and appeal activities comply with federal, state, and payer-specific regulations, including maintaining knowledge of ICD-10-CM/PCS coding guidelines and CMS regulations. u00b7 Maintain accurate records of denial appeals in the designated software, including the status of appeals, timelines, and outcomes. u00b7 Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windows. u00b7 Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgrades. u00b7 Meet departmental performance goals, including Key Performance Indicators (KPIs) related to denial turnaround times, appeal success rates, and denial reduction targets. Denials Prevention u00b7 Analyze denial patterns to identify root causes and collaborate on preventive strategies. u00b7 Proactively address discrepancies between payer policies, regulatory standards and internal processes to prevent future denials. u00b7 Develop and implement process improvements aimed at preventing denials, such as better workflows, enhanced communication between departments, or technology solutions. u00b7 Provide regular reports and feedback to leadership and relevant departments on denial prevention efforts, identifying areas needing attention. Education u00b7 Provide ongoing education to the coding and CDI teams regarding DRG validation, payer guidelines, and best practices to minimize future denials. Stays current on payer policies, regulatory changes, coding guidelines (e.g., ICD-10, DRG), and healthcare regulations that could impact denials and coding practices. Communication u00b7 Collaborate with Revenue Cycle and Medical Staff teams to ensure a unified approach to denial management and appeals. u00b7 Serve as the primary contact with payers on DRG-related denials. Effectively communicate the clinical and coding rationale for the DRG assignment and challenge inappropriate denials. u00b7 Respond to department inquiries regarding claim denials, explaining the resolution process and providing updates as needed. u00b7 Communicates across departments as needed. Other u00b7 Performs other related duties as required. u00b7 Mentors new and existing team members. u00b7 Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. _Working Relationships:_ This Job Reports To: Medical Director _Requirements and Specifications:_ Education u00b7 Minimum: Associate of Science in Nursing u00b7 Preferred: Bachelor of Science in Nursing Experience u2022 Minimum: Two (2) years of progressive on-the-job inpatient and/or clinical documentation experience within healthcare revenue cycle or other healthcare field. u00b7 Preferred: Three (3) years of progressive on-the-job experience with DRG denial management and appeals preferred. Licensure, Certification, Registration u2022 Active Registered Nurse license from the State of Connecticut u2022 Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP) Language Skills u2022 Strong written and verbal communication skills. Knowledge, Skills and Ability Requirements u2022 Strong understanding of ICD-10-CM/PCS coding, DRG assignment, and payer regulations related to DRG validation. u2022 Ability to analyze medical records, coding documentation, and payer denial reasons to determine appropriate appeal strategies. u2022 Excellent written and verbal communication skills, with the ability to clearly articulate clinical and coding justifications in appeal letters. u2022 Ability to manage multiple denials, prioritize tasks, and ensure timely submission of appeals. u2022 Experience with electronic health record (EHR) systems, coding software, and denial tracking tools. u2022 Proficient in tracking systems and data management tools. u2022 Strong organizational skills with a high level of accuracy and attention to detail. u2022 Strong interpersonal skills. u2022 Excellent communication and collaboration abilities. u2022 Strong problem-solving, analytical, and critical thinking skills. u2022 Experience working with cross-functional departments to research and resolve issues using innovative solutions. u2022 Ability to work independently. u2022 Ability to provide outstanding customer service. _We take great care of careers.___ With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge u2013 helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment. Job: Administrative Organization: Hartford HealthCare Corp. Title: Denial RN DRG Appeal Writer1 / HIM Coding Location: Connecticut-Farmington-9 Farm Springs Rd Farmington (10566) Requisition ID: 25164157

Created: 2025-12-05