Clinical DRG Denial Specialist
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Job Description
Clinical DRG Denial Specialist protecting Rochester Regional Health reimbursement through clinical appeals, coding review, and denial prevention. Supporting revenue integrity and regulatory compliance across the revenue cycle.
Responsibilities:
- Ensure accurate and timely resolution of DRG-related payer denials and audit activity
- Produce compliant appeal outcomes using clinical, coding, and payer policy knowledge
- Maintain contractual, regulatory, and documentation requirements across denial, appeal, and pre-bill review activities
- Identify and address documentation, coding, and medical necessity risks before claim submission
- Analyze payer trends, denial patterns, and appeal outcomes to improve denial prevention
- Maintain denial-related information, requirements, and case status for tracking and reconciliation
- Promote standardized denial and appeal practices and efficient workflows
- Apply clinical and coding expertise to support accurate DRG assignment, documentation integrity, and reimbursement outcomes
Requirements:
- Degree in Nursing
- NYS Registered Nurse Licensure
- AS: Health Information Management (Required)
- 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
- Ability to work Monday through Friday, 7:00 AM - 3:30 PM
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