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
- Conduct retrospective reviews for DRG downgrade denials.
- Draft appeals establishing medical necessity for diagnoses.
- Collaborate with teams on patient classification and reimbursement.
- Provide clinical staff training on DRG requirements.
- Ensure compliance with healthcare regulations and best practices.
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 (RN)
- Diagnosis-Related Group (DRG)
- Medical Necessity
- Retrospective Reviews
- Appeal Drafting
- Clinical Documentation
- Healthcare Regulations
- Patient Care
- Process Improvement
Skills & topics
- Clinical RN Specialist
- Registered Nurse
- RN
- DRG Downgrade
- Medical Necessity
- Utilization Review
- Case Management
- Clinical Documentation
- Healthcare Compliance
- Acute Care
How to get hired
- Tailor your resume: Highlight your RN license, DRG downgrade experience, and coding certifications (AAPC/AHIMA).
- Showcase clinical expertise: Emphasize your acute care, ICU, or utilization review background in your application.
- Demonstrate communication skills: Prepare examples of your ability to train staff and collaborate effectively.
- Understand CorroHealth's focus: Research their mission in clinical validation and process optimization.
- Prepare for case reviews: Be ready to discuss your approach to retrospective medical necessity reviews.
Technical preparation
Master DRG downgrade criteria and coding guidelines.,Practice writing clear medical necessity appeals.,Review ACDIS and AHIMA documentation standards.,Familiarize yourself with HIPAA and clinical workflows.
Behavioral questions
Describe a complex DRG downgrade case you handled.,How do you ensure accuracy in medical documentation?,How would you train nursing staff on new protocols?,How do you handle disagreements with payor denials?
Frequently asked questions
- What are the mandatory qualifications for the Clinical RN Specialist role at CorroHealth?
- The mandatory qualifications for the Clinical RN Specialist role at CorroHealth include an active, unrestricted Registered Nurse (RN) license and mandatory DRG downgrade experience. Additionally, a strong background in various clinical settings and computer proficiency are essential.
- Is DRG downgrade experience required for the Clinical RN Specialist position?
- Yes, DRG downgrade experience is a mandatory requirement for this Clinical RN Specialist position at CorroHealth. Candidates without this specific experience will not be considered.
- What type of clinical experience is preferred for the RN Specialist role?
- CorroHealth prefers candidates with a minimum of 5 years of recent acute-care hospital experience. Additionally, at least 2 years of Utilization Review or Case Management experience within the last 5 years is highly preferred, along with proven experience in critical care environments like the ICU.
- What coding certifications are beneficial for the Clinical RN Specialist job?
- While not strictly mandatory, being certified in coding through AAPC (CPC/COC) or AHIMA (CCS/CCS-P) is highly beneficial. Preferred certifications include CDIP or CCDS.
- What will a Clinical RN Specialist do at CorroHealth?
- As a Clinical RN Specialist at CorroHealth, you will perform retrospective medical necessity reviews, draft appeals for DRG downgrade denials, provide clinical staff education, and contribute to quality improvement initiatives.
- How does CorroHealth utilize the Clinical RN Specialist's expertise?
- CorroHealth utilizes the Clinical RN Specialist's expertise to evaluate hospitalizations nationwide, perform clinical case reviews, establish medical necessity for diagnoses, and optimize patient outcomes through improved documentation and compliance.
- What is the importance of medical necessity in this role?
- Establishing Medical Necessity for diagnoses is central to this role. You will draft appeals that demonstrate that the clinical criteria used in diagnosing the patient were appropriate and met necessary standards.
- What kind of training will the Clinical RN Specialist provide?
- The Clinical RN Specialist will provide targeted training and education to clinical staff on DRG requirements, medical terminology, anatomy, physiology, and documentation standards to ensure accurate coding and patient classification.