Apixio · 1 day ago

DRG Reviewer

United States

Full-time

Remote

Entry, Mid Level

$85K/yr - $105K/yr

2+ years exp

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Responsibilities

Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.

Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.

Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.

Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team.

Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and generate audit letters.

Makes recommendations for improvements to the audit system that enhance efficiency.

Assures HIPAA compliance for protected health information.

Other duties as assigned.

Qualification

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Nursing degreeHealth information management degreeRHIA certificationRHIT certificationCCDS certificationCDIP certificationCCS certificationCPC-H certificationCIC certificationInpatient claims auditingClinical Documentation IntegrityDRG methodologiesICD-10-CM/PCS codingCritical review judgmentUHDDS definitionsOfficial Coding GuidelinesAHA’s Coding Clinic GuidelinesHIPAA compliance

Required

Associate or bachelor’s degree in nursing (active/unrestricted license)

Associate or bachelor’s degree in health information management

Work experience may be considered in lieu of formal education at leadership discretion

At least one of the following certifications is required: RHIA - Registered Health Information Administrator, RHIT- Registered Health Information Technician, CCDS – Certified Clinical Documentation Specialist, CDIP – Clinical Documentation Improvement Practitioner, CCS - Certified Coding Specialist, CPC-H, Certified Professional Coder-H (Hospital Based), CIC, Certified Inpatient Coder

Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required

Inpatient Clinical Documentation Integrity experience of 2 years or more required

Exhibits high standards for quality and attention to detail

Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors

Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations

Solid knowledge and understanding of clinical criteria and documentation requirements to successfully substantiate code assignments

Subject matter expert in DRG methodologies (e.g., MS & APR)

Subject matter expert in ICD-10-CM/PCS coding methodologies, UHDDS definitions, Official Coding Guidelines and AHA’s Coding Clinic Guidelines

Demonstrates ability to work efficiently and effectively with minimal direct supervision