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. The DRG Reviewer examines medical records to validate accuracy of the UB and items billed for accurate DRG assignment along with appropriate customer payment policies applied to each case reviewed. The DRG Reviewer must be able to work independently with minimal supervision. Strong customer service skills are required.

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.

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.

Skills

• 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.
• Demonstrated ability to work efficiently and effectively with minimal direct supervision.
• Experience working with laptops and multiple monitors.
• Experience working remotely.
• Working knowledge of Windows office systems including full Microsoft Suite and Teams.
• Experience with various forms of software and experience engaging development teams.
• Experience with Encoder/Grouper programs (TruCode/3M) and/or similar coding and auditing tools.

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

Pay

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.