Overview
This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.
Responsibilities
- Analyzes and Audits Claims. Integrates medical chart coding principles, clinical guidelines and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.
- Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
- Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.
- Meets or Exceed Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim.
- identification and documentation (letter writing).Identifies New Claim Types.
- Identifies potential claims outside of the concept where additional recoveries may be available.
- Suggests and develops high quality, high value concept and or process improvement, tools, etc.
- Complete all responsibilities as outlined on annual Performance Plan.
- Complete all special projects and other duties as assigned.
- Must be able to perform duties with or without reasonable accommodation.
- Complete all responsibilities as outlined on annual Performance Plan.
- Complete all special projects and other duties as assigned.
- Must be able to perform duties with or without reasonable accommodation.
Qualifications
Education (at least one of the following are required)
- Associate or bachelor's degree in nursing (active /unrestricted license).
- Associate or bachelor's degree Health Information Management (RHIA or RHIT).
- High school diploma or GED plus equivalent experience of 5+ years' experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment.
Coding/CDI Certification (at least one of the following are required and are to be maintained as a condition of employment):
- RHIA or RHIT.
- CPC.
- Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.
Experience (required)
- 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
- Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codes.
- Requires working knowledge of and applicable industry-based standards.
- Proficiency in Word, Access, Excel, TEAMS, and other applications.
- Excellent written and verbal communication skills.
Mental Requirements
- Communicating with others to exchange information.
- Assessing the accuracy, neatness, and thoroughness of the work assigned.
Physical Requirements and Working Conditions
- Remaining in a stationary position, often standing or sitting for prolonged periods.
- Repeating motions that may include the wrists, hands, and/or fingers.
- Must be able to provide a dedicated, secure work area.
- Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
- No adverse environmental conditions expected.
Base compensation is paid hourly at $45.67 per hour (95k annualized). This role is eligible for discretionary bonus consideration.
Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.