Job Description

The DRG Coding & Clinical Validation Auditor is responsible for auditing client data and generating high quality recoverable claims for the benefit of our clients. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered. Key Responsibilities:

• Identifies and Enters Claims. Integrates medical chart coding principles and objectivity in performance of medical audit activities. Draws on advanced ICD-9 and ICD-10 coding expertise and industry knowledge to substantiate conclusions. Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues, and quality concerns.
• Effectively Utilizes Audit Tools . Utilizes with advanced proficiency, and client tools required to perform duties. Enters the claim into client system accurately and in accordance with standard procedures. Updates current reports, develops and runs custom queries and validates accuracy of current reports used. Makes determinations based on prior knowledge, experience of client contract terms with the likelihood of recovery acceptance.
• Meets or Exceeds Standards/Guidelines for Productivity . Maintains production goals and quality standards set by the audit for the auditing concept. Audits against the expected level of quality and quantity (i.e. hit rate, # claims written, ID per hour).
• Meets or Exceed Standards/Guidelines for Quality. Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
• Prepares Responses to Client Disputes . Provides independent verification of claims validation, insurance or employer validation in a concise written manner.
• Reviews Provider Contracts. Demonstrates high level of expertise in researching requirements necessary to make recommendations on client contracts to fit projects within standard reports such as medical policies and state and federal statutes.
• Identifies New Claim Types . Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high quality, high value concept and or process improvement, tools, etc.
• Recommends New Concepts and Processes . Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience. Suggests, develops and implements new ideas, approaches and or technological improvements that will support and enhance audit production, communication and client satisfaction. Evaluate information and draw logical conclusions. Collaborates with Data Services in developing new reports.

• Must be a Registered Nurse (US RN or PH RN)
• Must have DRG auditing or inpatient coding experience and must have active coding license
• Clinical experience an advantage but not required
• Amenable to rotational night and dayshift