DRG Claims Auditor, Recoveries

Responsibilities

• Perform DRG validation and quality audit on claims, providing coding expertise in the application of medical and reimbursement policies within the claim adjudication process through document review, interpretation of state and federal mandates, applicable benefit language, coding requirements and consideration of relevant clinical information with a focus on overpayment identification.
• Utilize expert clinical knowledge and judgement to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance.
• Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment. Ability to write clearly and succinctly in a variety of communication settings and styles. Excellent communication and presentation skills across various levels and through multiple channels (oral, written, conversational). Strong quantitative and analytical skills.
• Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Review and analyze facility and professional claims in support of MGBHP's medical and payment policies and CMS guidelines. Apply knowledge and experience during decision-making process. Complete and document audits based on established guidelines. Provide input on and research of claims challenged by the providers.
• Identify and provide analytical data on billing trends/issues for potential areas of recoveries. Regularly reviews to identify enhancement to the audit methodology and documentation requirements. Provide clinical support and expertise to the other investigative and analytical areas. Identify potential audit concepts and notify Manager of Provider Audit of any leads, in support of next steps or escalation to outside agencies.
• Maintain and manage daily case review assignments, with a high emphasis on quality. Work in a high-volume production environment that is matrix driven.

Qualifications:

• Associate's degree required or the equivalent combination of training and experience, plus 3-5 years of related experience. Bachelor's degree preferred
• Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), CPC-H (hospital) or CCS (Certified Coding Specialist), or RHIT required.
• Nursing license preferred.
• 5+ years in DRG Validation role performing DRG claims auditing, quality assurance, or recovery auditing required.
• Thorough knowledge of ICD-10, ICD-10-PCS, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS, and Revenue Billing Codes.

Knowledge, Skills, and Abilities

• Superior Microsoft Suite and Excel Skills required.
• Being a strong team player.
• Excellent project management skills.
• Familiarity with the regulatory environment for financial services.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Strong work ethic and focus on quality work.
• Understanding of general accounting principles.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
• Strong verbal, active listening, and written communication skills required.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity

Working Conditions:

• This is a remote role that can be done from most US states
• Monday through Friday, standard business hours (ET) are required