Job Description

Job description:



We are seeking a detail-oriented Inpatient Denials & Appeals Specialist to support revenue integrity efforts by managing and appealing payer denials related to DRG validation and reimbursement determinations. This role is responsible for evaluating medical records, coding accuracy, and clinical documentation to build strong appeal cases and recover appropriate reimbursement.

The ideal candidate will possess a strong background in inpatient coding, denial management, and regulatory compliance. This position works closely with revenue cycle, coding, clinical documentation, and compliance teams to identify denial trends, resolve reimbursement challenges, and support ongoing process improvements.

Essential Responsibilities

Denial Review & Appeals Management

• Evaluate inpatient medical records, coding assignments, and supporting clinical documentation to assess payer denial determinations.
• Investigate DRG downgrades and validation denials to determine appeal opportunities.
• Develop, prepare, and submit comprehensive appeal packages supported by coding guidance, clinical evidence, and applicable reimbursement regulations.
• Track and manage appeal activity from submission through final resolution, ensuring all actions are documented accurately within designated systems.
• Monitor payer deadlines and filing requirements to ensure appeals are submitted within required timeframes.
• Support reimbursement recovery initiatives by challenging inappropriate denials and minimizing revenue loss.

Compliance & Documentation Integrity

• Maintain current knowledge of ICD-10-CM/PCS coding standards, DRG methodologies, CMS requirements, and payer-specific guidelines.
• Ensure denial and appeal activities comply with federal regulations, state requirements, and contractual payer policies.
• Review documentation for completeness, consistency, and clinical support of assigned diagnoses, procedures, and DRG assignments.
• Adhere to established coding ethics and professional standards while maintaining confidentiality and accuracy in all work performed.

Denial Prevention & Process Improvement

• Analyze denial data and identify recurring trends, root causes, and areas of risk.
• Partner with internal stakeholders to reduce future denials through education, workflow enhancements, and documentation improvement initiatives.
• Recommend corrective actions when discrepancies are identified between organizational practices, payer expectations, or regulatory standards.
• Contribute to process optimization efforts that improve appeal success rates and strengthen revenue cycle performance.
• Stay informed of industry updates, payer policy revisions, and regulatory changes affecting inpatient reimbursement and denial management.

Additional Duties

• Perform other responsibilities and special projects as assigned.
• Demonstrate commitment to the ethical standards established by the American Health Information Management Association (AHIMA) and applicable coding guidelines.

Required Qualifications

• RHIA or RHIT with a CCS required.
• Minimum of 3 years of experience in healthcare denial management, clinical documentation integrity (CDI), health information management.
• Strong understanding of inpatient coding practices, DRG assignment methodologies, and clinical documentation requirements as well as experience reviewing payer denials and developing successful appeal strategies.
• Proficiency with electronic health records (EHRs), coding applications, and claims management systems.
• Excellent written, verbal, analytical, and organizational skills.

Preferred Skills & Competencies

• Advanced problem-solving and critical-thinking skills.
• Knowledge of Medicare, Medicaid, and commercial payer reimbursement requirements.
• Strong attention to detail with the ability to prioritize multiple deadlines as well as the ability to work independently and collaboratively.
• Experience providing education and guidance related to denial prevention and revenue integrity initiatives.
• Customer-focused mindset with a commitment to quality and accuracy.

About Health Information Partners:

At HIP, we are dedicated to excellence in health information management. Our team values collaboration, professionalism, and the unique skills each member brings to the table. We strive to create a positive and rewarding work environment for all our employees.

How to Apply:

If you’re ready to bring your expertise to a dynamic and supportive team, we’d love to hear from you! Submit your application and updated resume to Careers@hip-inc.com today.