Appeal Analyst RN I

Job Summary

The primary responsibility of this position is to lead on-site and desk audits of hospital billing and coding practices. This role supports audit protocol development, trend analysis, profiling, and special audit projects. The position performs and finalizes audits related to per diem billing, bill verification, DRG validation (utilization review audits), and credit balances. Additionally, the role provides guidance and education to stakeholders regarding ICD-10-CM coding, DRG assignment, payment methodologies, and audit processes.

Key Responsibilities

• Conduct on-site and desk audits of hospital billing and coding practices.

• Identify and communicate billing discrepancies discovered during audits and coordinate referrals for improper claim payments through appropriate channels.

• Analyze and identify error trends related to medical record documentation, billing documentation, or misinterpretation of provider contract terms.

• Compile audit statistics and prepare reports for accounts, regulatory agencies, and internal stakeholders.

• Review and update audit processes in collaboration with management to align with evolving clinical data review practices and cost-containment initiatives.

• Train and mentor new staff on department procedures and audit methodologies.

• Perform special projects and assignments as requested by management.

• Maintain compliance with all applicable laws, regulations, policies, and organizational standards.

This job description is intended to describe the general nature and level of work performed by employees within this classification. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required for the role.

Education & Experience

• High School Diploma or GED required.

• Bachelors degree in Health Information Management preferred; equivalent relevant experience may be considered in lieu of a degree.

• Minimum of 3 years of experience in a medical records department within an acute care hospital or healthcare facility.

• Experience with DRG validation, ICD-10-CM training, and medical coding education required.

Licensure & Certifications

• Active RN license required.

• Certified Coding Specialist (CCS) certification required.

Knowledge Requirements

• Strong knowledge of medical terminology, anatomy and physiology, disease processes, treatment protocols, procedural drug therapies, ancillary services, and diagnostic procedures.

• Knowledge of utilization management principles.

• Understanding of hospital organizational structures and reimbursement/payment systems.

• Knowledge of Medicare and Medicaid prospective payment system regulations.

• Familiarity with ACCESS software preferred.