The DRG Validation position focuses on auditing inpatient medical records to ensure accurate coding, provider documentation, and DRG assignment. This role requires strong expertise in MS-DRG and APR-DRG payment systems, ICD-10-CM/PCS coding, and hospital reimbursement policies.
Key Responsibilities
- Perform concurrent and retrospective clinically based MS-DRG and APR-DRG validation reviews in compliance with UHDDS, Medicare guidelines, and federal/state regulations.
- Review the correct assignment of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes.
- Use facility encoders, EMRs, abstracting systems, and auditing tools such as 3M, Epic, and TruCode to support audit determinations.
- Write clear and concise rationales supporting audit findings.
- Prepare physician queries for documentation clarification.
- Educate coders and other healthcare professionals based on audit findings.
- Review DRG/coding denial letters and draft appeal responses supporting hospital determinations.
- Provide recommendations for optimal coding and DRG/SOI assignment.
- Stay current on regulatory and coding rule changes.
- Maintain high productivity and accuracy standards, including a 95% to 100% quality accuracy rate.
- Communicate effectively with physicians, CDI staff, and other clinicians regarding documentation and coding guidelines.
Requirements & Qualifications
Qualifications
- AHIMA certification required: CCS, RHIT, or RHIA.
- Extensive knowledge of medical terminology, anatomy, coding terminology, and ICD-10-CM/PCS, CPT, and modifier guidelines.
- 5+ years of experience in DRG/clinical validation, claims auditing, quality assurance, or recovery auditing.
- 5+ years of experience working with ICD-10-CM/PCS, MS-DRG, and APR-DRG.
- Strong understanding of medical claims billing/payment systems and payer reimbursement policies.
- Knowledge of Official Coding Guidelines, Coding Clinic determinations, CMS requirements, and regulatory compliance standards.
- Proficiency with Microsoft Outlook, Word, Excel, PowerPoint, 3M, TruCode, Teams, and SharePoint.
- Strong written and verbal communication skills.
- Ability to educate healthcare professionals in various settings.
- Strong analytical, research, and time management skills.
- Must meet or exceed deadline completion expectations.
Experience
- ICD coding experience: 5 years required
- AHIMA certification required
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
3 weeks ago
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