Inpatient Coding Appeals Specialist
Sales Rain BPO Inc. Cebu Full-time
Key Responsibilities:
- Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignments.
- Analyze payer denials involving:
▫ DRG downgrades
▫ Removal of CC/MCC
▫ Clinical validation denials
▫ Coding validation disputes- Prepare clear, concise, and compliant DRG appeal letters supported by:
▫ ICD-10-CM/PCS Official Guidelines
▫ UHDDS reporting requirements
▫ eCMS rules and industry references (e.g., AHA Coding Clinic, AHIMA guidance)- Defend secondary diagnoses and MCC/CC assignments based on provider documentation and coding standards
- Collaborate with clinical reviewers, CDI teams, and revenue cycle leadership to resolve complex cases
- Ensure timely filing of appeals in accordance with payer and client deadlines
- Accurately document appeal outcomes and maintain tracking logs for productivity, quality, and turnaround time
- Participate in quality audits, peer reviews, and continuous process improvement initiatives
- Maintain strict compliance with HIPAA and data privacy regulations.
Required Qualifications:
- Inpatient Coding Experience (required)
- Strong working knowledge of:
▫ ICD-10-CM and ICD-10-PCS
▫ MS-DRG and APR-DRG systems
▫ CC/MCC logic and DRG impact- Demonstrated experience handling DRG appeals or inpatient coding denials
- Ability to interpret complex medical documentation and translate findings into defensible appeal narratives.
- Excellent written communication skills with the ability to cite official coding and clinical references.
- High attention to detail, critical thinking, and strong analytical skills.
- Ability to work independently while meeting productivity and quality benchmarks
Sales Rain BPO Inc.Cebu City
Key Responsibilities:
• Review and analyze claims that have been denied due to coding-related issues, including diagnosis codes (ICD-10-CM), procedure codes (CPT/HCPCS), and related modifiers.
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Key Responsibilities
• Review denied medical claims to determine reasons for denial (coding errors, missing information, medical necessity, eligibility, etc.).
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