Work where every moment mattersEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkThe creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole rather than a single member organizationWith the creation of our new umbrella organization we now have our own identity with a unique payroll benefits performance management system service recognition programs and other common practices across the system Position SummaryThe Denial Specialist is responsible for reviewing analyzing and appealing denials related to DRG Diagnostic Related Group downgrades This role involves validating the coding and clinical accuracy ensuring proper documentation and collaborating with other departments to address payer concerns Key responsibilities include timely investigation of DRG downgrades submitting appeals coordinating follow up actions and ensuring compliance with regulatory standards The specialist also plays a critical role in preventing future downgrades by identifying trends and providing feedback to improve coding and clinical documentation practices Position ResponsibilitiesKey Areas of ResponsibilityDenial Resolutionmiddot Conduct a thorough review of medical records coding and clinical documentation to validate or appeal payer denialsmiddot Prepare document and submit appeals for DRG denials ensuring appeals are well supported with clinical evidence coding guidelines and regulatory requirementsmiddot Work closely with the Clinical Documentation Improvement CDI and Coding teams to ensure accurate DRG assignment and enhance documentation practices that support appropriate reimbursementmiddot Ensure that all DRG denial and appeal activities comply with federal state and payer specific regulations including maintaining knowledge of ICD CMPCS coding guidelines and CMS regulationsmiddot Maintain accurate records of denial appeals in the designated software including the status of appeals timelines and outcomesmiddot Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windowsmiddot Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgradesmiddot Meet departmental performance goals including Key Performance Indicators KPIs related to denial turnaround times appeal success rates and denial reduction targetsDenials Preventionmiddot Analyze denial patterns to identify root causes and collaborate on preventive strategiesmiddot Proactively address discrepancies between payer policies regulatory standards and internal processes to prevent future denialsmiddot Develop and implement process improvements aimed at preventing denials such as better workflows enhanced communication between departments or technology solutionsmiddot Provide regular reports and feedback to leadership and relevant departments on denial prevention efforts identifying areas needing attentionEducationmiddot Provide ongoing education to the coding and CDI teams regarding DRG validation payer guidelines and best practices to minimize future denials Stays current on payer policies regulatory changes coding guidelines eg ICD DRG and healthcare regulations that could impact denials and coding practicesCommunicationmiddot Collaborate with Revenue Cycle and Medical Staff teams to ensure a unified approach to denial management and appealsmiddot Serve as the primary contact with payers on DRG related denials Effectively communicate the clinical and coding rationale for the DRG assignment and challenge inappropriate denialsmiddot Respond to department inquiries regarding claim denials explaining the resolution process and providing updates as neededmiddot Communicates across departments as neededOthermiddot Performs other related duties as requiredmiddot Mentors new and existing team membersmiddot Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines Working RelationshipsThis Job Reports To Medical DirectorWork where every moment mattersEvery day more than Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkThe creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole rather than a single member organizationWith the creation of our new umbrella organization we now have our own identity with a unique payroll benefits performance management system service recognition programs and other common practices across the system Position SummaryThe Denial Specialist is responsible for reviewing analyzing and appealing denials related to DRG Diagnostic Related Group downgrades This role involves validating the coding and clinical accuracy ensuring proper documentation and collaborating with other departments to address payer concerns Key responsibilities include timely investigation of DRG downgrades submitting appeals coordinating follow up actions and ensuring compliance with regulatory standards The specialist also plays a critical role in preventing future downgrades by identifying trends and providing feedback to improve coding and clinical documentation practices Position ResponsibilitiesKey Areas of ResponsibilityDenial Resolutionmiddot Conduct a thorough review of medical records coding and clinical documentation to validate or appeal payer denialsmiddot Prepare document and submit appeals for DRG denials ensuring appeals are well supported with clinical evidence coding guidelines and regulatory requirementsmiddot Work closely with the Clinical Documentation Improvement CDI and Coding teams to ensure accurate DRG assignment and enhance documentation practices that support appropriate reimbursementmiddot Ensure that all DRG denial and appeal activities comply with federal state and payer specific regulations including maintaining knowledge of ICD CMPCS coding guidelines and CMS regulationsmiddot Maintain accurate records of denial appeals in the designated software including the status of appeals timelines and outcomesmiddot Monitor appeal deadlines to ensure timely submission of all required documentation and compliance with payer appeal windowsmiddot Contribute to revenue protection efforts by successfully overturning inappropriate denials and reducing the financial impact of DRG downgradesmiddot Meet departmental performance goals including Key Performance Indicators KPIs related to denial turnaround times appeal success rates and denial reduction targetsDenials Preventionmiddot Analyze denial patterns to identify root causes and collaborate on preventive strategiesmiddot Proactively address discrepancies between payer policies regulatory standards and internal processes to prevent future denialsmiddot Develop and implement process improvements aimed at preventing denials such as better workflows enhanced communication between departments or technology solutionsmiddot Provide regular reports and feedback to leadership and relevant departments on denial prevention efforts identifying areas needing attentionEducationmiddot Provide ongoing education to the coding and CDI teams regarding DRG validation payer guidelines and best practices to minimize future denials Stays current on payer policies regulatory changes coding guidelines eg ICD DRG and healthcare regulations that could impact denials and coding practicesCommunicationmiddot Collaborate with Revenue Cycle and Medical Staff teams to ensure a unified approach to denial management and appealsmiddot Serve as the primary contact with payers on DRG related denials Effectively communicate the clinical and coding rationale for the DRG assignment and challenge inappropriate denialsmiddot Respond to department inquiries regarding claim denials explaining the resolution process and providing updates as neededmiddot Communicates across departments as neededOthermiddot Performs other related duties as requiredmiddot Mentors new and existing team membersmiddot Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines Working RelationshipsThis Job Reports To Medical DirectorRequirements and SpecificationsEducationmiddot Minimum Associate of Science in Nursingmiddot Preferred Bachelor of Science in NursingExperiencebull Minimum Two years of progressive on the job inpatient andor clinical documentation experience within healthcare revenue cycle or other healthcare fieldmiddot Preferred Three years of progressive on the job experience with DRG denial management and appeals preferredLicensure Certification Registrationbull Active Registered Nurse license from the State of Connecticutbull Certified Clinical Documentation Specialist CCDS Certified Documentation Integrity Practitioner CDIPLanguage Skillsbull Strong written and verbal communication skillsKnowledge Skills and Ability Requirementsbull Strong understanding of ICD CMPCS coding DRG assignment and payer regulations related to DRG validationbull Ability to analyze medical records coding documentation and payer denial reasons to determine appropriate appeal strategiesbull Excellent written and verbal communication skills with the ability to clearly articulate clinical and coding justifications in appeal lettersbull Ability to manage multiple denials prioritize tasks and ensure timely submission of appealsbull Experience with electronic health record EHR systems coding software and denial tracking toolsbull Proficient in tracking systems and data management toolsbull Strong organizational skills with a high level of accuracy and attention to detailbull Strong interpersonal skillsbull Excellent communication and collaboration abilitiesbull Strong problem solving analytical and critical thinking skillsbull Experience working with cross functional departments to research and resolve issues using innovative solutionsbull Ability to work independentlybull Ability to provide outstanding customer service We take great care of careers With locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour moment Requirements and SpecificationsEducationmiddot Minimum Associate of Science in Nursingmiddot Preferred Bachelor of Science in NursingExperiencebull Minimum Two years of progressive on the job inpatient andor clinical documentation experience within healthcare revenue cycle or other healthcare fieldmiddot Preferred Three years of progressive on the job experience with DRG denial management and appeals preferredLicensure Certification Registrationbull Active Registered Nurse license from the State of Connecticutbull Certified Clinical Documentation Specialist CCDS Certified Documentation Integrity Practitioner CDIPLanguage Skillsbull Strong written and verbal communication skillsKnowledge Skills and Ability Requirementsbull Strong understanding of ICD CMPCS coding DRG assignment and payer regulations related to DRG validationbull Ability to analyze medical records coding documentation and payer denial reasons to determine appropriate appeal strategiesbull Excellent written and verbal communication skills with the ability to clearly articulate clinical and coding justifications in appeal lettersbull Ability to manage multiple denials prioritize tasks and ensure timely submission of appealsbull Experience with electronic health record EHR systems coding software and denial tracking toolsbull Proficient in tracking systems and data management toolsbull Strong organizational skills with a high level of accuracy and attention to detailbull Strong interpersonal skillsbull Excellent communication and collaboration abilitiesbull Strong problem solving analytical and critical thinking skillsbull Experience working with cross functional departments to research and resolve issues using innovative solutionsbull Ability to work independentlybull Ability to provide outstanding customer service We take great care of careers With locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour moment