DRG and Clinical Appeals Specialist
Second Wave Delivery Systems · Posted Nov 8, 2026
- Remote, United States
- Remote
- $95K–$135K per year
- 5+ years
Cross‑functional revenue integrity specialist focused on clinical and DRG appeals, validation audits, coding compliance reviews, and denial‑prevention activities.
Compensation
$95,000–$135,000
Responsibilities
- Review denied claims involving DRG downgrades, clinical validation and coding denials.
- Conduct comprehensive analysis of medical records, coded data, physician documentation, laboratory results, imaging findings, treatments, and patient outcomes to identify appeal opportunities.
- Draft clear, persuasive, evidence‑based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.
- Prepare first‑level and second‑level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.
- Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, acute kidney injury, malnutrition, encephalopathy, and other MCC/CC conditions.
Requirements
- Bachelor’s degree in nursing, Health Information Management, or a related healthcare field
- Nice to have: Experience writing successful payer appeals
- Nice to have: Certifications: CCDS, CDIP, CCS, RHIA, RHIT, CPC, CRC