DRG Downgrade Specialist - Remote

DRG Downgrade Specialist

Who we are:

At Lifepoint Health, we provide quality healthcare to rural communities. As a valued member of our team, you will be an integral part of a group working together to elevate Lifepoint's healthcare delivery network. Our network includes 60+ community hospitals, 60+ rehabilitation/behavioral health hospitals, and 250 additional sites of care across the United States. As an organization, we are dedicated to serving communities nationwide by providing exceptional care. We believe in the power of our talented teams and strive to create environments where employees find purpose and fulfillment.

What you'll do:

As a DRG Downgrade Specialist, you will conduct a thorough review of the medical record and drafting appeal letters, preparing for peer-to-peer and/or ALJ hearings and discussing cases with clinical and coding teams. This position will support Lifepoint's increased focus on DRG downgrades (payor reimbursement changes due to a change in the coding submitted on the billing claim form). This position will enable the coding and CDI teams to bridge communication and coordination gaps driven from use of different systems and terminologies. This role will serve as a navigator for the process flow and denial appeals of complex clinical coding cases.

Responsibilities:

• Responsible for conducting medial record reviews and responding to insurance DRG downgrades. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Responsible for the denials process, including subsequent appeal letters.

• Assures appropriate action is taken within appeal time frames to address DRG downgrade.

• Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome.

• On a monthly basis presents identified denial trends and patterns and creates education on root cases and preventable measures.

• Utilizes appropriate applications to accurately track clinical denial data; participates in the development and implementation of a system-wide process for appeals.

• Reviews and has knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations, National Coverage Determinations, Policy Bulletins, etc.

• Assists with continuous quality improvement of the established appeals process.

• Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.

• Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors.

• Other related job tasks or responsibilities as assigned.

What you'll need:

Education: Associate degree in health-related field required.

Required Experience: 2+ years of experience preparing appeals for DRG downgrades or writing clinical denials on behalf of payers. Strong knowledge of medicine and pathophysiology with understanding of clinical criteria and treatment of medical diagnoses

Preferred Experience: 3+ years of appeals, coding, or CDI experience; CPC, CCS or equivalent Coding Certification; Certification in Clinical Documentation Improvement (CCDS or CDIP)

Certifications: Nurse, medical school graduate, physician assistant (RN, NP, PA, MD, DO, MBBS) OR an RHIA/RHIT

Licenses: Current, unrestricted RN license (for RN applicants)

Why choose us:

As a team member of the Health Support Center, our goal is to support those that are in our facilities who are interfacing and providing care to our patients and community members. Our focus is to attract, retain, and empower a diverse and determined workforce. Our mission statement is at the heart of who we are and what we do: "Making Communities Healthier." In this shared mission, we believe that our collective efforts will shape a healthier future for the communities we serve.

Benefits: We offer an excellent total compensation package, including a competitive salary and benefits. Some of our benefits include 401k, flexible PTO, generous Employee illness benefit (EIB), medical, dental, vision, tuition reimbursement, and an Employee Assistance Program. We believe that happy, healthy people have a passionate engagement with life and work and have designed our package to enhance your wellbeing.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran