Specialist

RN Clinical Review Appeals Specialist

The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all diagnosis and procedure codes to assure properly assigned MS-DRG or APR-DRG for the purpose of appealing proposed DRG and coding changes by insurance providers or their respective auditors.

Job Duties And Responsibilities:

• Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG accuracy based on denials or audit findings from government and commercial payers. Meet or exceed established benchmarks for productivity while maintaining quality.
• Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding assignment of documented medical care for appropriate reimbursement.
• Work with the physician advisor in review of patient medical records identified by RAC/MIC/QIO and other governmental or commercial payor auditors in retrospective reviews for DRG and documentation or coding-related issues.
• Develop and apply appeal arguments and draft appeal letters to support and defend the codes assigned by the coding professionals and be able to refute the clinical validation or coding determination made by the government or commercial payors, or their auditor representative.
• Facilitate clinical chart reviews to assist with supporting assigned diagnosis and/or procedures codes of medical conditions as documented in the patient medical record and identify clinical documentation improvement issues and through excellent communication with physicians, coding and CDMP leadership, Quality Dept. coordinators, and other members of the health care team working independently and collaboratively to resolve such issues.
• Participate in Administrative Law Judge (ALJ) hearings and/or formal meetings with auditor or payor representatives in defense of coding appeals, as needed.
• Maintain necessary audit/appeal activity documents including Excel spreadsheets, EPIC Payor Audit Management tool, Word Documents, Outlook email/calendar, and other workflow communication tools. Possess ability to evaluate reports from Epic PAMs or spreadsheets as needed for workflow or identification of trends. Assists in preparing reports regarding denials to include volumes, number of appeals, case resolution, and impact on revenue and trending.
• Facilitates retrospective clinical record reviews for outpatient/CPT payor recommendations in collaboration with the OP Coding Supervisor or Network Coding Operations Director.
• Responsible for maintaining up-to-date, working knowledge of ICD-10-CM/PCS coding and MS-DRG principles and AHA coding guidelines.
• Responsible to remain current on clinical criteria as it pertains to Nuance Clinical Documentation Management Program strategies for clinical documentation or current program in use for clinical documentation improvement program, AHA Official Coding Guidelines for Coding and Reporting of diagnoses and procedures, AHA Coding Clinic.

Physical And Sensory Requirements:

Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation.

Education:

Registered Nurse required, BSN preferred. Current license required.

Training And Experience:

Minimum five (5) years RN/licensed provider experience in adult inpatient medical-surgical or critical care with thorough understanding of disease processes required. Background knowledge of HIM field helpful, with focus on MS-DRG reimbursement, AHA coding guidelines, and compliance or direct Clinical Documentation Improvement experience. Previous audit experience preferred. Working knowledge of ICD-10-CM/PCS. Knowledge of reimbursement systems, regulations and policies pertaining to documentation, coding and as needed, medical necessity. Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.

St. Luke's University Health Network is an Equal Opportunity Employer.