Inpatient Appeals Specialist

Job Summary

The Inpatient Appeals Specialist is responsible for reviewing, analyzing, and appealing denials related to DRG (Diagnostic Related Group) downgrades. This role ensures coding and clinical accuracy, proper documentation, and compliance with regulatory standards. You will collaborate with internal teams, investigate DRG downgrades, submit appeals, and help prevent future denials by identifying trends and improving documentation practices.

Key Areas of Responsibility

• Conduct a thorough review of medical records, coding and clinical documentation to validate or appeal payer denials.
• Prepare, document and submit appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory requirements.
• 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.
• Maintain accurate records of denial appeals in the designated software, including the status of appeals, timelines, and outcomes.
• Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windows.
• Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgrades.

Denials Prevention

• Analyze denial patterns to identify root causes and collaborate on preventive strategies.
• Proactively address discrepancies between payer policies, regulatory standards and internal processes to prevent future denials.
• Develop and implement process improvements aimed at preventing denials, such as better workflows, enhanced communication between departments, or technology solutions.
• Stays current on payer policies, regulatory changes, coding guidelines (e.g., ICD-10, DRG), and healthcare regulations that could impact denials and coding practices.

Other

• Performs other related duties as required.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.

Qualifications

• RHIA or RHIT with a CCS Required
• Minimum 3 years’ experience in denial management, clinical documentation integrity, or health information management.
• Strong clinical knowledge and understanding of documentation requirements, DRG validation, and quality measures.
• Excellent analytical, organizational, and communication skills.
• Proficient with electronic health records and medical claims processing systems.

Desired Competencies

• Ability to lead and educate others in denial management processes
• Knowledge of Medicare, Medicaid, and commercial payer regulations
• Strong attention to detail and ability to work independently and collaboratively
• Effective problem-solving and customer service skills

About Health Information Partners: At HIP, we are dedicated to excellence in health information management. Our team values collaboration, professionalism, and the unique skills each member brings to the table. We strive to create a positive and rewarding work environment for all our employees.

How to Apply: If you’re ready to bring your expertise to a dynamic and supportive team, we’d love to hear from you! Submit your application and updated resume to Careers@hip-inc.com today.

Job Types: Part-time, Contract, Temporary

Application Question(s):

• 1. What are your credentials?
• 2. Have you worked with EPIC or other electronic health record (EHR) systems?
• 3. How many years of experience do you have in denial management?
• 4. Describe your experience in writing appeal letters?
• 5. Are you available to start immediately, or do you require a notice period?
• 6. Do you have experience working independently in a remote environment with minimal supervision?
• 7. What is your hourly salary expectation for this position?

Work Location: Remote