Clinical RN Specialist

📋 Description

• • Perform retrospective medical necessity reviews to determine appeal eligibility for clinical validation DRG Downgrade denials.
• • Construct and document succinct, fact-based clinical cases to support appeals by establishing medical necessity of diagnoses challenged by payors or third-party audit firms.
• • Utilize appropriate medical necessity criteria and pertinent clinical facts, including verification that diagnostic criteria applied to the patient were clinically appropriate.
• • Adhere strictly to coding and clinical documentation guidelines endorsed by ACDIS and AHIMA in all appeal documentation.
• • Review hospitalization records across the United States to evaluate clinical validity of DRG downgrades issued by payors.
• • Draft detailed, legally defensible appeal letters that clearly articulate clinical rationale for overturning denial decisions.
• • Maintain accurate and organized case records in compliance with internal documentation standards and regulatory requirements.
• • Collaborate with internal teams to ensure alignment on clinical interpretations and appeal strategies.
• • Stay current with evolving Medicare and private payer policies related to DRG coding, medical necessity, and utilization review.
• • Work full-time Monday through Friday in a fully remote environment within the United States.
• • Operate computer systems for 6–8 hours daily to review electronic medical records, draft appeals, and manage case tracking tools.
• • Function effectively in a high-volume, deadline-driven environment with frequent interruptions and elevated stress during peak activity periods.
• • Apply clinical expertise gained from recent acute-care hospital experience to assess complex patient cases and justify medical necessity.
• • Ensure all documentation meets certification standards for coding professionals (AAPC or AHIMA) and supports audit readiness.
• • Participate in ongoing professional development opportunities to enhance clinical, coding, and appeal advocacy skills.
• • Maintain active, unrestricted RN or MD license in at least one U.S. state at all times during employment.