The Clinical Appeals Specialist is responsible for reviewing and preparing clinical and coding-related appeals for denied or downgraded healthcare claims. This role involves analyzing medical documentation, applying ICD-10 coding guidelines, and utilizing MCG/InterQual criteria to support medical necessity and DRG validation. The ideal candidate has experience in clinical appeals writing, medical coding, CDI, or DRG downgrade review within a US healthcare environment.
Key Responsibilities
- Review denied, downgraded, or disputed healthcare claims and prepare comprehensive appeal documentation
- Analyze medical records to support medical necessity and coding accuracy
- Interpret and apply ICD-10-CM/PCS coding guidelines, MCG, and InterQual criteria
- Evaluate DRG assignments, including MS-DRG and APR-DRG methodologies
- Prepare clear, concise, and evidence-based clinical appeal letters
- Collaborate with coding, CDI, utilization review, and clinical teams to gather supporting documentation
- Ensure compliance with payer guidelines, CMS regulations, and organizational standards
- Maintain productivity, quality, and turnaround time expectations
- Identify trends or recurring denial patterns and escalate concerns when necessary
- Participate in process improvement initiatives and team discussions
Qualifications
- At least 6 months to 1+ year of Clinical Appeals Writing experience
- Experience handling DRG downgrade appeals or coding appeals preferred
- Background in Medical Coding, Clinical Documentation Improvement (CDI), or DRG validation/review
- Strong understanding of ICD-10 coding guidelines
- Familiarity with MCG and/or InterQual guidelines
- Experience with MS-DRG and APR-DRG methodologies is highly preferred
- US healthcare industry experience required
- Excellent analytical, critical thinking, and written communication skills
- Ability to work independently in a remote setup
