I have over five years of experience in healthcare revenue cycle management, specializing in DRG denials. My role involved reviewing denied claims, identifying root causes such as coding errors or documentation gaps, and preparing appeals with supporting clinical evidence. I am proficient in using tools like ICD-10 coding, clinical documentation improvement (CDI) systems, and payer-specific guidelines to ensure accurate and timely appeals. My success rate in overturning denials exceeds 80%, and I consistently collaborate with coding teams and clinicians to address systemic issues.

I stay current by attending webinars, subscribing to industry newsletters, and participating in professional organizations like AHIMA and AAPC. I also regularly review updates from CMS and major payers to ensure compliance with the latest coding and billing regulations. Additionally, I collaborate with internal teams to share insights and implement process improvements. This proactive approach ensures that I can effectively navigate policy changes and minimize denials due to outdated practices.

One challenging case involved a denied claim for a complex sepsis diagnosis due to insufficient documentation. I worked closely with the clinical team to gather additional evidence, including lab results and physician notes, and crafted a detailed appeal letter. By aligning the documentation with coding guidelines and payer requirements, I successfully overturned the denial, recovering over $50,000 in revenue. This experience reinforced the importance of collaboration and attention to detail in resolving high-stakes denials.

I prioritize cases based on factors like financial impact, appeal deadlines, and complexity. I use a tracking system to monitor progress and ensure timely follow-ups. For high-value or urgent cases, I allocate more resources and collaborate with cross-functional teams to expedite resolution. By maintaining organized workflows and clear communication, I effectively manage my caseload while meeting organizational goals for denial recovery and revenue integrity.

I focus on proactive measures such as educating clinical and coding teams on common denial triggers and documentation best practices. I also conduct regular audits to identify trends and address gaps before claims are submitted. By fostering collaboration between departments and leveraging data analytics, I help implement process improvements that reduce denial rates and enhance overall revenue cycle performance.