Specialist, DRG Denials & Appeals

NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children's hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. At NYU Langone Health, equity, diversity, and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive. We embrace diversity, inclusion, and individual skills, ideas, and knowledge. For more information, go to nyulangone.org, and interact with us on LinkedIn, Glassdoor, really, Facebook, Twitter, YouTube and Instagram.

Position Summary:
We have an exciting opportunity to join our team as a Specialist, DRG Denials & Appeals.

In this role, the successful candidate as the DRG Denials and Appeals Specialist analyzes and responds to DRG Denials across the NYU Langone Enterprise. Formulates timely written appeal responses to Third Party Payors, RAC, and all other DRG payment denials based on expertise in Clinical Validation and Coding practices as outlined by AHIMA, AHA, coding Clinic, the AMA, CMS, UHDDS Data Element Definitions, and Evidence-based Practice Literature. Assists with the development and maintenance of Policies and Procedures relating to the Denials Process. Maintains metrics of Denial trends for reporting purposes and for use as an educational tool for Coder and Clinical Documentation Improvement education and training.

Job Responsibilities:

• Analyzes adverse determinations and potential DRG Re-assignments from various Third Party Payors.
• Reviews denied cases by using pre-established criteria, and determines whether or not an appeal is warranted.
• Formulates responses to DRG RAC, MIC, MAC etc. payment denials following Department wide Standards of Practice and within contractual timeframes.
• Works in conjunction with Management to formulate and maintain metrics for reporting to the organization’s Revenue Cycle Leadership.
• Assists with the development of Provider, Health Information Management and Clinical Documentation Improvement educational projects.
• Collaborates with Physician Advisor and HIM team to review denials and coordinate the appeal process as needed.
• Performs other duties as assigned.

Minimum Qualifications:
To qualify you must have a Bachelors degree in Nursing or other health related field or Health Information Management.
3-5 years of acute care hospital experience in Nursing or other Health related field OR 3-5 years of Coding and Clinical Validation experience
Evidence of maintaining ongoing responsibility for professional development.
Effective communication (verbal and written) and interpersonal skills.
Strong critical thinking and analytical skills.
Demonstrated ability to handle multiple assignments and carry out work independently with minimal supervision.
Willingness to work a flexible schedule to ensure compliance with deadlines.
Ability to work collaboratively in a team environment.
Proficient with Microsoft applications and working knowledge of EPIC and other hospital based clinical computer systems.
Certified Coding Specialist Certification (CCS) within three years of hire..

Required Licenses: Certified Coding Specialist

Preferred Qualifications:
Completion of ICD-10 CM Continuing Education Course
Three to five years acute care hospital experience in medical record chart review.
Three years of current experience with reimbursement methodologies.
Experience preparing appeals for DRG Denials
Certification in Clinical Documentation Improvement (CCDS or CDIP)
Certified Coding Specialist Certification (CCS)

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
If you wish to view NYU Langone Health's EEO policies, please click here. Please click here to view the Federal "EEO is the law" poster or visit https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm for more information.

NYU Langone Health provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $76,721.84 - $120,000.00 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

To view the Pay Transparency Notice, please click here


Required Skills

Required Experience