Job Description
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, utilizatio...