Senior DRG Appeals Nurse Reviewer

• Location: Remote (Up to 25% travel for onsite hearing testimony)

• Compensation: $95,000 – $110,000 base + $5,000 sign-on bonus

Position Summary

The Senior DRG Appeals Nurse Reviewer is responsible for reviewing and resolving provider appeals related to DRG validation and reimbursement determinations. This position plays a critical role in evaluating medical records, analyzing clinical and coding documentation, developing appeal rationale, and supporting case presentation during hearings. The ideal candidate will blend clinical nursing expertise, coding proficiency, and deep familiarity with appeals, audits, or payment integrity processes.

Key Responsibilities

• Review and evaluate provider appeals and reconsideration requests involving DRG assignments, coding accuracy, and reimbursement determinations.

• Analyze medical records, coding documentation, and supporting clinical evidence to determine whether appeal requests meet established criteria and guidelines.

• Prepare well-written, fact-based appeal determinations and supporting rationale.

• Develop comprehensive case summaries and supporting documentation for administrative hearings.

• Participate in virtual and onsite hearings in collaboration with clinical and medical leadership.

• Maintain productivity and quality metrics while managing multiple cases simultaneously.

• Serve as a resource to peers and assist with onboarding, mentoring, and training new team members.

• Remain current on coding regulations, clinical guidelines, reimbursement methodologies, and industry best practices.

• Cross-train across multiple review types to support operational and client needs.

Qualifications & Requirements

Licensure & Certifications

• Active, unrestricted Compact Registered Nurse (RN) license.

• Must hold at least one of the following active certifications:

  • CPC (Certified Professional Coder)

  • CCS (Certified Coding Specialist)

  • CPMA (Certified Professional Medical Auditor)

Experience & Core Skills

• Minimum of 5 years of combined experience in one or more of the following areas:

  • Clinical nursing

  • Medical coding

  • Claims review or auditing

• Working experience with InterQual and/or Milliman guidelines.

• Working knowledge of healthcare appeals, reimbursement review, or administrative hearing processes.

• Strong understanding of clinical documentation and comprehensive medical record review.

• Excellent written communication skills, with the ability to draft clear, defensible appeal determinations.

• Excellent verbal presentation skills and the ability to confidently discuss case findings during hearings.

• Strong organizational and time-management skills, with the ability to manage competing priorities in a fast-paced environment.

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