Appeals JD

DRG Denial Specialist

Role Summary:

The DRG Denial Specialist is responsible for reviewing and resolving denied inpatient claims related to DRG validation, coding accuracy, and medical necessity. The role involves detailed clinical and coding analysis, preparation of solid appeal documentation, and ensuring optimal reimbursement from payers.

Key Responsibilities:

- Review and analyze denied inpatient claims focusing on DRG validation, coding accuracy, and medical necessity.
- Evaluate Explanation of Benefits (EOBs) and denial reasons to identify root causes.
- Perform detailed review of physician documentation and clinical records to support appeals.
- Prepare and submit evidence-based appeal letters aligned with CMS and coding guidelines.
- Apply in-depth knowledge of ICD-10-CM/PCS coding guidelines and DRG methodologies (MS-DRG/APR-DRG).
- Ensure adherence to Medicare, Medicaid,



and commercial payer guidelines while handling denials.
- Collaborate with coding, CDI, and clinical teams to resolve discrepancies and strengthen appeal outcomes.
- Track appeal status and follow through to resolution for maximum reimbursement.

Qualifications:

- Clinical background:

- MBBS or
- B.Sc. Nursing with active NCLEX-RN
- Minimum 3+ years of experience in DRG appeals, Medical necessity, DRG validation, or inpatient denial management.

Preferred Qualifications:

- Certification such as CCS or CPC preferred.
- Experience in US Healthcare Revenue Cycle Management (RCM).
- Strong understanding of payer audit processes and regulatory compliance
- Work Mode - Remote (Chennai ,HYD,BLR,NCR)

📌 DRG Denial Specialist - Appeals (Hyderabad)
🏢 CorroHealth
📍 Hyderabad