Clinical RN Specialist (Active RN License & DRG Downgrade Experience REQ'D)
CorroHealth · United States
- Hybrid
- Full-time
- $95,000 / year
- United States
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Job highlights
- Evaluate hospitalizations nationwide for DRG downgrades.
- Perform retrospective reviews and draft appeal cases.
- Ensure accuracy in patient documentation and coding.
- Educate clinical staff on DRG requirements and best practices.
- Collaborate for optimal patient classification and reimbursement.
About the role
Clinical RN Specialist - CorroHealth
We are seeking a highly skilled and dedicated Clinical RN Specialist to join our healthcare team. The ideal candidate will possess an active Registered Nurse (RN) license and extensive experience in Diagnosis-Related Group (DRG) downgrades (MANDATORY), with a strong background in various clinical settings. This role involves providing expert guidance on patient care, medical documentation, and hospital protocols to optimize patient outcomes and ensure compliance with healthcare regulations. The Clinical RN Specialist will serve as a vital resource for clinical education, process improvement, and interdisciplinary collaboration within our organization.
You will have the unique opportunity to evaluate hospitalizations across the country while utilizing your medical knowledge and gaining experience as an expert advisor. You will perform retrospective clinical case reviews and draft appeals that focus on establishing the Medical Necessity of diagnosis in question by the payor or 3rd party audit firm.
Responsibilities:
- Performs retrospective medical necessity reviews to determine appeal eligibility of clinical validation DRG Downgrade denials.
- Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.
- Pertinent clinical facts include, but are not limited to, documenting that the clinical criteria utilized in diagnosing the patient was appropriate.
- Adheres to all coding and clinical documentation guidelines as endorsed by ACDIS and AHIMA.
- Conduct comprehensive reviews of patient records to identify opportunities for DRG downgrades, ensuring accurate documentation and coding.
- Collaborate with medical staff, case managers, and billing teams to facilitate appropriate patient classification and reimbursement processes.
- Provide targeted training and education to clinical staff on DRG requirements, medical terminology, anatomy, physiology, and documentation standards.
- Assist in developing and implementing policies that enhance clinical workflows, compliance with HIPAA regulations, and medical record accuracy.
- Monitor ongoing patient care activities to ensure adherence to best practices in acute care, ICU protocols, pediatrics, nursing home standards, and home care procedures.
- Support quality improvement initiatives by analyzing clinical data related to patient care outcomes and DRG performance metrics.
- Maintain up-to-date knowledge of healthcare regulations, medical terminology, anatomy, physiology, and industry best practices to serve as a subject matter expert.
Minimum Qualifications & Competencies:
- RN or MD degree with strong clinical knowledge - Active unrestricted clinical license in at least one state within the United States.
- DRG downgrade experience is mandatory.
- Certified in coding through either the AAPC (CPC/COC) or AHIMA (CCS/CCS-P) - CDIP or CCDS certification is preferred.
- Minimum of 5 years recent acute-care hospital experience, preferred.
- Minimum of 2 years Utilization Review / Case Management experience within the last 5 years.
- Must have excellent written communication skills and be computer proficient.
- Proven experience in critical care environments such as ICU or acute care units with a focus on DRG management.
- Extensive nursing background including hospital experience, nursing home care, teaching hospital exposure, pediatrics, or home health settings.
- Strong understanding of medical documentation processes, coding practices, and medical records management.
- Excellent knowledge of medical terminology, anatomy, physiology, and patient care procedures across diverse clinical disciplines.
- Demonstrated ability to train and develop healthcare staff through adult education techniques and instructional design.
- Familiarity with HIPAA compliance standards and confidentiality protocols in handling sensitive patient information.
- Effective communication skills for interdisciplinary collaboration and delivering clear educational content.
Join our team as a Clinical RN Specialist to leverage your expertise in DRG downgrades while advancing clinical excellence through education and process optimization.
Key skills/competency:
- Clinical RN Specialist
- Registered Nurse
- DRG Downgrade Experience
- Medical Necessity Review
- Clinical Documentation
- Coding Guidelines
- Healthcare Regulations
- Patient Care
- Utilization Review
- Case Management
Skills & topics
- Clinical RN Specialist
- Registered Nurse
- RN
- DRG Downgrades
- Medical Necessity
- Clinical Documentation
- Coding
- Utilization Review
- Case Management
- Healthcare
- Hospital
- Acute Care
- ICU
- Appeals
- Reimbursement
- ACDIS
- AHIMA
- HIPAA
How to get hired
- Tailor your resume: Highlight your RN license, DRG downgrade experience, and 5+ years of acute care background.
- Showcase coding certifications: Emphasize CPC, COC, CCS, CCS-P, CDIP, or CCDS certifications.
- Demonstrate communication skills: Prepare examples of effective written and verbal communication for reviews and training.
- Understand healthcare regulations: Be ready to discuss HIPAA and coding guidelines (ACDIS, AHIMA).
- Research CorroHealth: Learn about their focus on clinical validation and process optimization.
Technical preparation
Master DRG downgrade review processes.,Practice writing concise clinical appeal cases.,Review ACDIS and AHIMA coding guidelines.,Familiarize with HIPAA and medical necessity criteria.
Behavioral questions
Describe a complex DRG downgrade you managed.,How do you ensure accuracy in documentation?,Explain your process for educating clinical staff.,How do you handle disagreements with payors?
Frequently asked questions
- What is the most critical requirement for the Clinical RN Specialist role at CorroHealth?
- The most critical requirement for the Clinical RN Specialist position at CorroHealth is an active Registered Nurse (RN) license and mandatory, extensive experience in Diagnosis-Related Group (DRG) downgrades. Without this specific experience, candidates will not be considered.
- Does CorroHealth require specific coding certifications for the Clinical RN Specialist job?
- Yes, CorroHealth requires certification in coding through either the AAPC (CPC/COC) or AHIMA (CCS/CCS-P). While preferred, CDIP or CCDS certifications are also valuable for the Clinical RN Specialist role.
- What kind of clinical background is preferred for the Clinical RN Specialist position?
- CorroHealth prefers candidates with a minimum of 5 years of recent acute-care hospital experience. Experience in utilization review or case management within the last 5 years, and proven experience in critical care environments like the ICU, are also highly valued for this role.
- Will I be evaluating cases from my local area or nationwide as a Clinical RN Specialist at CorroHealth?
- As a Clinical RN Specialist at CorroHealth, you will have the opportunity to evaluate hospitalizations across the country, utilizing your medical knowledge and serving as an expert advisor on a national scale.
- What is the primary focus of the retrospective reviews conducted by the Clinical RN Specialist?
- The primary focus of the retrospective reviews for the Clinical RN Specialist role at CorroHealth is to determine the appeal eligibility of clinical validation DRG downgrade denials. This involves drafting appeals to establish the medical necessity of diagnoses questioned by payors or third-party auditors.
- What are the key responsibilities regarding training and education for the Clinical RN Specialist?
- The Clinical RN Specialist is responsible for providing targeted training and education to clinical staff. This includes educating them on DRG requirements, medical terminology, anatomy, physiology, and documentation standards to ensure compliance and optimize patient outcomes.
- How important is knowledge of healthcare regulations for this role?
- Knowledge of healthcare regulations is crucial for the Clinical RN Specialist. This includes a strong understanding of HIPAA compliance standards and confidentiality protocols, as well as adherence to coding and clinical documentation guidelines endorsed by ACDIS and AHIMA.