Clinical Denial Specialist – Diagnosis Related Grouping (DRG)

WVU Medicine

. Manage timely review and responses to enterprise hospital billing audits received electronically and by mail .

Posted 10/27/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in hospital billing audits, clinical appeals, and revenue cycle management while effectively collaborating with stakeholders to maximize revenue recovery. Proficient in applying CMS guidelines, coding conventions, and maintaining current clinical knowledge.

Highest-signal resume keywords

Hospital Billing ManagementClinical Appeals WritingRevenue Cycle CoordinationCoding Standards ApplicationDenial Management

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Documentation ImprovementInpatient CodingDRG Accuracy EvaluationDiscrepancy CalculationAudit Response Management

Soft Skills

Independent WorkCollaborationNegotiationCommunication

Tools & Technologies

EpicExcelSolventumWellingtonMSDRG/DRG Groupers

Certifications & Qualifications

RN LicenseLPN LicenseRHITRHIACCDSCDIPCCSCIC

Industry Keywords

Healthcare AdministrationAcute Care SettingComplianceHIMUHDDS Guidelines

About the role

Key responsibilities & impact

Manage timely review and responses to enterprise hospital billing audits received electronically and by mail
Write and submit clinical appeals for insurance denials
Review patient medical records for clinical relevance, procedure relevance, DRG accuracy, complications, and comorbidities using UHDDS guidelines
Identify discrepancies between billed and documented services and calculate discrepancy amounts
Evaluate supporting information using CMS, coding, and clinical practice standards
Negotiate disputed billing issues with external auditors and provide supporting documentation
Maintain denial correspondence and update the denial database
Coordinate appeals with stakeholders and aggressively appeal denials to maximize revenue recovery
Collaborate with clinical, coding, revenue cycle, compliance, HIM/ROI, and educational stakeholders
Develop educational materials, presentations, learning tools, and process-improvement initiatives
Apply payer policies, CMS guidelines, coding conventions, and hierarchical rules
Provide denial-management information and recommendations to leadership
Work independently with minimal supervision and maintain current clinical and coding knowledge

Requirements

What you’ll need

Associate degree in healthcare administration, Nursing, Health Information Management, or related field and five (5) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle; OR bachelor’s degree in a related field and three (3) years of such experience
Current RN or LPN license, including qualifying multi-state eNLC license, OR RHIT, RHIA, CCDS, CDIP, CCS, or CIC certification
Preferred: two (2) years of hospital appeals/denials, HIM, or compliance experience
Preferred: seven (7) years of experience in hospital billing, acute care setting, CDI, inpatient coding, or revenue cycle
Preferred: strong technology skills, including Epic, Excel, Solventum, Wellington, and MSDRG/DRG groupers