[Hiring] Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III @company

Role Description

The Payment Integrity DRG Coding & Clinical Validation Analyst position has an extensive background in acute facility-based clinical documentation, and/or inpatient coding and has a high level of understanding of the current MS-DRG, and APR-DRG payment systems. This position is responsible for reviewing medical records for appropriate provider documentation to support the principal diagnosis, co-morbidities, complications, secondary diagnosis, surgical procedures, POA indicators to validate coding and DRG assignment accuracy, ensuring the physician documentation supports the hospital coded data.

Qualifications

• Associate or bachelor’s degree in health information management (RHIA or RHIT) or a Nursing Degree.
• Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting.
• Three (3) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology.
• Coding Certification is to be maintained as a condition of employment of one of the following: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC.
• Intermediate analytical and problem-solving skills; as well as keeps abreast of latest trends related to business analysis.
• Intermediate knowledge of PC, software, auditing tools and claims processing systems.

Requirements

• Level I:
• Analyzes and audits acute inpatient claims.
• Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
• Establishes national and best practice benchmarks and measures performance against benchmarks.
• Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
• Manages case volumes and review/audit schedules, prioritizing case load as assigned by Management.
• Consistently demonstrates high standards of integrity.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Level II (in addition to Level I Accountabilities):
• Performs complex audits or projects with minimal direction or oversight.
• Acts as an expert in reviewing medical coding and medical record review.
• Supports leadership in projects related to divisional/departmental strategies and initiatives.
• Participates and represents in audits, payment methodologies, contractual agreements.
• Serves as a mentor to new hires.
• Demonstrates ability to participate and represent department on internal/external committees.
• Level III (in addition to Level II Accountabilities):
• Provides expertise in developing data criteria for audits.
• Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members.
• Serves as an expert and resource for escalations.
• Provides backup support for Management as necessary.

Benefits

• Participation in group health and/or dental insurance.
• Retirement plan.
• Wellness program.
• Paid time away from work.
• Paid holidays.

Compensation Range(s)

• Level I: Grade E4: Minimum: $65,346 - Maximum: $117,622
• Level II: Grade E5: Minimum: $71,880 - Maximum: $129,384
• Level III: Grade E6: Minimum: $79,068 - Maximum: $142,322