Overview
This DRG Validation Auditor role is focused on our Cross Claim Clinical Reviews (CCCR). Auditors in this role will be doing DRG Validation for our prepay and retrospective audits and making determinations without a medical record. The ideal candidate for this position needs to have both a strong inpatient HIM/coding background and an understanding of clinical validation. 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, services delivered and patient history.
This is a Full-Time role, scheduled to work an off-hour shift from either 3 PM-11 PM or 11 PM-7 AM ET, including weekends & holidays. (No PT or PRN availability)
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.