DRG Coding Auditor

About This Role

The DRG Coding Auditor is responsible for auditing inpatient medical records and generating high-quality recoverable claims for all lines of business. This role involves performing clinical reviews of medical records and other documentation to evaluate coding and DRG assignment accuracy.

Responsibilities

• Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines and objectivity in the performance of medical audit activities
• Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters
• Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes
• Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available
• Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations

Requirements

• AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing
• RHIA, RHIT, CCS, or CIC certification
• 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG

Qualifications

• AA/AS or BA/BS preferred
• 5+ years of experience in claims auditing, quality assurance, or recovery auditing. 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Nice to Have

• BA/BS degree
• Experience with vendor based Diagnosis-Related Group (DRG) Coding/Clinical Validation Audit setting or hospital coding or quality assurance environment
• Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology
• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation

Skills

* Required skills

Benefits

Certifications