Health Business Solutions LLC

Key Responsibilities

Review inpatient medical records to validate principal diagnosis, secondary diagnoses (CC/MCC), procedures, and DRG assignment.

• Analyze payer denials involving:

o DRG downgrades

o Removal of CC/MCC

o Clinical validation denials

o Coding validation disputes

• Prepare clear, concise, and compliant DRG appeal letters supported by:

o ICD-10-CM/PCS Official Guidelines

o UHDDS reporting requirements

o CMS 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:

o ICD-10-CM and ICD-10-PCS

o MS-DRG and APR-DRG systems

o 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