UnitedHealth Group · 1 day ago

DRG CVA RN Auditor

United States

Full-time

Remote

Mid Level

$33.75/hr - $66.25/hr

3+ years exp

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Responsibilities

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification

Utilize expert knowledge 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

Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments

Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing

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

Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics

Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly

Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements

Maintain and manage daily case review assignments, with a high emphasis on quality

Provide clinical support and expertise to the other investigative and analytical areas

Work in a high-volume production environment that is matrix driven

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

MS-DRG codingAPR-DRG codingICD-10 codingRN licenseCCS certificationICD-10-CM codingICD-10-PCS codingDRG encoder toolsMicrosoft ExcelHealthcare claims experienceManaged care experienceWindows PC proficiency

Required

Associate’s Degree (or higher)

Unrestricted RN (Registered Nurse) license

CCS/CIC or willing to obtain certification within 6 months of hire

3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies

2+ years of ICD-10-CM coding experience including but not limited to: expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)

2+ years of ICD-10-PCS coding experience including but not limited to: expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers