Clinical Reimbursement Manager; DRG Manager; Mount Sinai Hospital

About the role

The purpose of DRG validation is to confirm that diagnostic, procedural information, and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician’s description and the information contained in the beneficiary’s medical record.

Responsibilities

• Performs SMART focused reviews on ICD-10-CM/PCS coded inpt medical records to validate accuracy of codes assigned, selection of principal diagnosis/principal procedure, & to identify missed addt'l diagnoses/procedures in accordance w/ coding guidelines.
• Validates the accuracy and appropriateness of the DRG assignments flagged pre-billing.
• Determines if a secondary review is required to verify assignment of Patient Safety Indicators, HAC, Clinical Documentation Improvement, Sepsis and any other charts meeting criteria for secondary review.
• Initiates an MD query to clarify documentation in the medical record for documentation, integrity and accurate code assignment essential to support documentation of medical diagnoses or conditions that are clinically evident.
• Reviews coder queries to determine if the query is supported and generates query to provider.
• Reviews cases with coding and/or DRG changes proposed by insurers, vendors, PFS to reconcile coding and/or DRG discrepancies.
• Provides feedback to coders on all coding changes thru SMART by documenting detailed rationale for change in both SMART and 3MHDM.
• Updates Artifact, 3M-360 and HDM with all query responses and selects the correct response to designate impact.
• Investigates reason for unbilled accounts or PFS edits due to diagnoses, procedures or DRGs, acts to combine stays, clears SPARCs edits, & provide missing dates of procedures or dialysis treatment.
• Resolves edits and rebills cases in 3M.
• Reviews and reconciles DRG discrepancies between DRGS/APR’s and the Clinical Documentation Quality Improvement (CDQI) department.
• Develops and maintains a close working relationship with CDQI staff.
• Consistently meets established productivity and quality targets for work assignments.
• Responds timely to email notifications and team messages from DRGV management.
• Communicates, cooperates and maintains open communication with DRG management, CDI, Coders, and departmental staff.
• Adheres and enforces all requirements related to HIPAA and confidentiality, privacy and security of patient records.

Qualifications

• A strong background in anatomy, physiology, pharmacology and working experience with ICD-10-CM and ICD-10-PCS coding is required.
• Minimum of 3 to 5 years of experience coding in an acute care hospital. Validation and auditing experience preferred.
• Excellent current knowledge of MS-DRGs, APR-DRGs reimbursement methodology.
• Good working knowledge of electronic health records, registration and data systems.