Clinical DRG Denials Specialist

Job Title: Clinical DRG Denial Specialist Location: Remote Schedule: Per Diem SUMMARY: The Clinical DRG Denials Specialist applies clinical knowledge, coding principles, payer policy interpretation, and documentation review to support appropriate reimbursement and regulatory compliance and works to protect organizational reimbursement by ensuring the accurate review, appeal, and resolution of DRG-related payer denials. Additionally, the position proactively works to identify documentation and coding risks before claim submission to reduce avoidable denials and strengthen revenue integrity. Through analysis of denial trends and appeal outcomes, the role helps improve processes and support denial prevention strategies across the revenue cycle. RESPONSIBILITIES: • Ensures accurate and timely resolution of DRG-related payer denials and audit activity in order to protect reimbursement and minimize avoidable revenue loss. • Produces well-supported and compliant appeal outcomes by applying clinical, coding, and payer policy knowledge to disputed DRG determinations. • Maintains adherence to contractual, regulatory, and documentation requirements across denial, appeal, and pre-bill review activities to support compliance and payment integrity. • Strengthens revenue integrity by identifying and addressing documentation, coding, and medical necessity risks before claim submission. • Improves denial prevention performance through analysis of payer trends, denial patterns, and appeal outcomes, leading to responsive strategies and process enhancements. • Ensures denial-related information, requirements, and case status are consistently maintained to support accurate tracking, reconciliation, and operational visibility. • Promotes effective, standardized denial and appeal practices that support efficient workflows and consistent organizational response to payer challenges. • Applies specialized clinical and coding expertise to support accurate DRG assignment, documentation integrity, and sustainable reimbursement outcomes across the revenue cycle. REQUIRED QUALIFICATIONS: Degree in Nursing NYS Registered Nurse Licensure PREFERRED QUALIFICATIONS: Knowledge of Epic preferred Proficient in Microsoft Office applications preferred Practical experience with computerized encoding and grouping software preferred Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist certification (CCS) preferred. BSN preferred. EDUCATION: LICENSES / CERTIFICATIONS: PHYSICAL REQUIREMENTS: S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations. PAY RANGE: $37.50 - $43.25 CITY: Rochester POSTAL CODE: 14617 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts. Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.