The DRG Validator position requires an extensive background in inpatient DRG coding with a deep understanding of the MS-DRG and APR-DRG payment systems. The role involves auditing inpatient medical records to ensure accuracy of coding, provider documentation, and DRG assignment.
Key responsibilities include performing concurrent and retrospective clinically based MS-DRG and APR DRG validation reviews aligned with Uniform Hospital Discharge Date Set (UHDDS) and Medicare guidelines, reviewing ICD-10-CM diagnosis and ICD-10-PCS procedure code assignments, utilizing facility encoders and auditing tools such as 3M, EPIC, TruCode proficiently, writing clear rationales supporting audit findings, composing physician queries, providing coder education referencing applicable coding references, reviewing DRG/coding denial letters and composing appeal responses to auditors and insurance carriers, providing recommendations for optimal coding and DRG/SOI assignments, and staying current on regulatory changes affecting coding rules and regulations.
The position requires meeting or exceeding productivity and quality goals set by the Director of HIM Technical Services with a quality accuracy rate of 95-100%. Effective communication with physicians, CDI staff, and other clinicians is essential to discuss documentation and coding guidelines.
Must hold one of the following AHIMA certifications: CCS, RHIT, or RHIA.
Extensive knowledge of medical terminology, anatomy, coding terminology, and coding guidelines for ICD-10-CM/PCS, CPT, and Modifiers.
Minimum 5 years of experience in DRG/Clinical Validation claims auditing, quality assurance, or recovery auditing, including experience working with ICD-10-CM/PCS, MS-DRG, and APR-DRG.
Broad knowledge of medical claims billing/payment systems and payer reimbursement policies.
Strict adherence to Official Coding Guidelines for Coding and Reporting, Coding Clinic determinations, CMS, and other regulatory compliance guidelines.
Proficiency with Microsoft Outlook, Word, Excel, PowerPoint, 3M, TruCode, Teams, SharePoint, and related applications.
Strong written and verbal communication skills.
Ability to educate health care professionals in various settings.
Responsible, self-sufficient, with strong analytical and research skills.
Ability to meet or exceed deadline completion times.
401(k) with matching Dental insurance Flexible schedule Health insurance Life insurance Paid time off Vision insurance
Work setting: Remote Schedule: 8 hour shift
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Salary Range
From $80,000
Remote work allowed
Yes
Posted
2 months ago