[Hiring] DRG Validation Coding Auditor @Ensemble Health Partners

Role Description

The Inpatient/DRG Validation Coding Auditor performs documentation and coding audits for all acute inpatient services for clients. Responsibilities include:

• Identifying coding errors, compliance, and educational opportunities.
• Optimizing reimbursement by ensuring that diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements.
• Performing independent reviews, interpreting medical records, and applying in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns.
• Demonstrating high level of expertise in researching requirements necessary to make compliant recommendations.
• Conducting DRG coding and clinical reviews to verify the accuracy of coding, DRG assignment, and clinical indicators in accordance with coding and documentation guidelines.
• Ensuring that the assigned DRG reflects the severity of the patient’s condition and the resources used during their hospital stay.
• Assessing whether the clinical documentation supports the coded diagnoses and procedures.
• Verifying that the medical record adequately justifies the assigned DRG.
• Combining medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders.
• Working closely with CDI specialists to determine documentation and/or query opportunities.
• Maintaining productivity and quality goals as set by audit leaders.
• Writing clear, accurate, and concise recommendations in support of findings while providing feedback and education to acute inpatient coders.
• Ensuring acute inpatient coding audits are completed accurately and timely by meeting client turnaround and audit quality expectations.
• Responsible for maintaining current certification(s), CEUs, and up-to-date knowledge of coding guidelines.
• Completing required education through internal application, compliance training, and other mandatory educational requirements.
• Using proprietary systems and encoder tools efficiently and accurately to make audit determinations.
• Identifying any potential overpayments or underpayments by analyzing claims.
• Leveraging ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions.
• Identifying potential opportunities for additional recoveries or compliance concerns.

Qualifications

• 5+ years of coding experience.
• 3+ years of facility coding audit experience (such as DRG and APC Validation).
• Proficiency in multiple EMRs, encoders, and the Microsoft Office suite.
• Educated in HIPAA regulations; must maintain strict confidentiality of patient and client information.
• Consistently achieves quality and productivity standards.
• Ability to organize and complete work in a timely manner.
• Ability to read, write, and effectively communicate in English.
• Ability to understand medical/surgical terminology.
• Above average written and verbal communication skills.
• Must be inquisitive and demonstrate openness to innovation including AI.

Requirements

• Bachelor's Degree or Equivalent Experience.
• Certification Required: Candidates must have and keep current at least one of the following professional certifications (CCS Preferred):
  • CPC (Certified Professional Coder)
  • CCS (Certified Coding Specialist)
  • RHIA (Registered Health Information Administrator)
  • RHIT (Registered Health Information Technician)

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement