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Ensemble Health Partners · 5 hours ago

DRG Validation Coding Auditor

United States

Full-time

Remote

Mid, Senior Level

5+ years exp

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems. The DRG Validation Coding Auditor performs documentation and coding audits for acute inpatient services, identifies coding errors, and ensures compliance with coding standards to optimize reimbursement.

Health CareHospitality

Responsibilities

Performs documentation and coding audits for all acute inpatient services for clients

Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements

Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns

Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations

Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines

Ensures that the assigned DRG reflects the severity of the patient’s condition, and the resources used during their hospital stay

Assesses whether the clinical documentation supports the coded diagnoses and procedures

Verifies that the medical record adequately justifies the assigned DRG

Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders

Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities

Maintains productivity and quality goals as set by audit leaders

Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics

Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations

Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines

Completes required education through internal application, compliance training and other mandatory educational requirements

Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately

Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided

Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions

Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies

Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns

Shares and assists in development of concepts and or process improvement, tools, etc

Qualification

DRG codingICD-10 codingCoding auditsClinical documentationCPC certificationCCS certificationRHIA certificationRHIT certificationEMR proficiencyHIPAA regulationsMedical terminologyCommunication skillsOrganizational skillsTeam collaboration

Required

5+ years of coding experience

3+ years of facility coding audit experience (such as DRG and APC Validation)

Proficiency in multiple EMR's, 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

Bachelors Degree or Equivalent Experience

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)

Has an extensive understanding of reimbursement guidelines, specifically related to DRG (MS, APR, Tricare, etc.) payment systems

Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines

Assesses whether the clinical documentation supports the coded diagnoses and procedures

Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders

Maintains productivity and quality goals as set by audit leaders

Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders

Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations

Responsible for maintaining current certification(s), CEU's, and up-to-date knowledge of coding guidelines

Completes required education through internal application, compliance training and other mandatory educational requirements

Use proprietary systems and encoder tools efficiently and accurately to make audit determinations

Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided

Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions

Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns

Benefits

Bonus Incentives

Paid Certifications

Tuition Reimbursement

Comprehensive Benefits

Career Advancement

Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.

Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.

Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.