DRG Reviewer (Onsite - Hendersonville, TN)

About the role

The Onsite DRG Reviewer is responsible for providing MS-DRG and APR-DRG audits services at provider locations on behalf of our clients. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery.

Responsibilities

• Claims Review: Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.
• Written Communication: Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.
• Collaboration: Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.
• Coding Knowledge: Maintains expert knowledge of ICD-10-CM/PCS coding conventions and rules, Official Coding Guidelines and American Hospital Association (AHA) Coding Clinic.
• Quality and Time Management: Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team, meets productivity requirements.
• Technically savvy: Ability to use multiple tools, provider systems, and different medical records systems to perform audits in a comprehensive and timely manner.
• Proficiency: Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and rationales.
• HIPAA Compliance: Assures HIPAA compliance for protected health information.
• Presentation skills: Participates in exit interviews with the client summarizing audit findings, which can vary depending on client/ facility.
• Practice Standards: Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Other duties as assigned.

Qualifications

• General: National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS).
• Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years’ experience performing DRG validation.
• Previous auditing/recovery experience preferred.
• Excellent oral and written communication skills.
• Comprehensive knowledge of the DRG structure and regulatory requirements.

Education

• (Required) Associate or bachelor’s degree in nursing (active/unrestricted license); or Associate or bachelor’s degree in health information management; or Work experience may be considered in lieu of formal education at leadership discretion.

Skills

• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS).
• ICD-10-specialized training.
• Comprehensive knowledge of the DRG structure and other health care payment methodologies and regulatory requirements.
• Minimum of five to seven years hospital inpatient coding for PPS reimbursement or at least 2 years experience performing DRG validation.
• Proven self-direction in the planning and execution of DRG validation and recovery functions.
• Confirmed effective communication in staff supervision and teaching.
• Proven operations analysis, including productivity and financial skills.
• Able to adhere to the highest ethical standards including honesty, integrity, dedication and leadership.
• Demonstrated ability to gain support for ideas and lead others to accomplish objectives.
• Demonstrated success rate in selection of cases that result in overpayment/recovery.
• Organization, flexibility and multiple task/project orientation to handle duties assigned.
• Skill in focusing on desired results, determining what is important and urgent, clarifying next steps, and delegating effectively to meet deadlines and achieve desired results.
• Excellent oral, written and presentation skills.
• Proficient in multiple computer applications (MS Office), DRG Grouper/Pricer software, and encoder software.

Benefits

• Top Medical/Dental/Vision offerings.
• FSA/HSATuition reimbursement.
• Competitive salary, 401(k) with company match.
• PTO.
• Additional health and wellness benefits and perks.
• Flexible and trusting environment where you’ll feel empowered to do your best work.

What We Offer

• Top Medical/Dental/Vision offerings.
• FSA/HSATuition reimbursement.
• Competitive salary, 401(k) with company match.
• PTO.
• Additional health and wellness benefits and perks.
• Flexible and trusting environment where you’ll feel empowered to do your best work.

Pay Range

$90,000 - $110,000

This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.

Equal Employment Opportunity at Machinify
We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process.