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DRG Appeals Nurse, RN
CorroHealth. Perform comprehensive reviews of inpatient medical records to validate MS/APR DRGs for Medicare, Commercial, and Third-Party paid claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity, including ICD-10-CM/PCS coding, MS/APR DRG payment methodologies, and regulatory compliance. Proficient in writing appeal letters and conducting comprehensive medical record audits while maintaining high production and quality standards.
Highest-signal resume keywords
RN LicenseInpatient Coding SkillsDRG Validation ExperienceClinical Validation ExpertiseCoding Certification (AHIMA or AAPC)
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
ICD-10-CM/PCS CodingDRG ValidationClinical Documentation IntegrityMedical Necessity AssessmentAppeal Letter WritingCritical ThinkingAudit Reference ToolsFact-Based Case ConstructionClinical Evidence AnalysisInpatient Payment Methodologies
Soft Skills
Excellent Written CommunicationExcellent Verbal Communication
Tools & Technologies
TruCode3M EncoderGrouper SoftwareMicrosoft OfficeTeamsWebExEHRs
Certifications & Qualifications
AHIMA CertificationAAPC CertificationCCSRHITRHIACPCCDIPCCDS
Industry Keywords
MS/APR DRGHACsPOA IndicatorsClinical GuidelinesEvidence-Based MedicineInpatient Coding Quality AssuranceDenial Management
About the role
Key responsibilities & impact- Perform comprehensive reviews of inpatient medical records to validate MS/APR DRGs for Medicare, Commercial, and Third-Party paid claims
- Validate ICD-10-CM/PCS codes, discharge disposition codes, HACs, and POA indicators affecting payment
- Ensure documentation is clinically supported and follows Official Coding Guidelines, compliant query practices, and current clinical validation criteria
- Use audit reference tools and applications, including proprietary denials management software, TruCode, and 3M encoder and grouper software
- Review denial-letter rationales and formulate custom appeal response letters
- Independently assess appeal cases for strengths and weaknesses
- Construct and document fact-based cases using clinical evidence, industry clinical guidelines, evidence-based medicine, and official coding guidelines
- Write professional appeal letters supporting each appeal argument
- Abstract denial audit findings into the proprietary application according to standard procedures
- Maintain subject-matter expertise in clinical validation, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies
- Attend continuing education workshops and webinars
- Meet production and quality expectations while performing complex medical record audits
- Perform other assigned responsibilities
Requirements
What you’ll need- Current and valid RN license in good standing
- Professional RN license must be maintained as a condition of employment
- Minimum of 5 years of experience in inpatient coding quality assurance, DRG validation, DRG appeal, or Clinical Documentation Integrity as a Clinical Documentation Specialist, Educator, or Manager
- DRG validation experience
- Medical necessity experience and appeal letter writing
- Extensive inpatient coding skills
- Regulatory ICD-10-CM/PCS coding expertise
- Subject matter expertise in MS/APR DRG payment methodologies, including HACs, POA assignment, and discharge disposition codes
- Clinical validation expertise, including current industry-standard clinical indicators, risk factors, and treatment protocols
- Knowledge of anatomy, physiology, pathology, laboratory, imaging, pharmacology, disease assessment, management, and treatment
- Strong critical thinking skills
- Excellent written and verbal communication skills
- Proficiency in Microsoft Office, Teams, WebEx, VPN access, various EHRs, and Internet connectivity troubleshooting
- Coding certification (AHIMA or AAPC) is a plus
- CCS preferred after one year of employment
- RHIT/RHIA/CPC is a plus
- CDIP or CCDS highly preferred
- Ability to work at a computer terminal for 6–8 hours a day
- Ability to lift and move material weighing up to 20 lbs. infrequently
Benefits
Comp & perks- Competitive salary
- Bonus opportunities
- Medical, Dental, and Vision coverage
- 401K
- Holidays
- Paid time off
- Short-term and long-term disability insurance
- Life insurance
- Reimbursement for continuing education and association dues
- Predictable schedule
- Flexible work environments
- Professional development and personal growth opportunities