DRG Reviewer - Remote

The DRG Reviewer is responsible for performing DRG payment validation (clinical/coding) reviews of medical records and/or other documentation as defined by contract specific review criteria. This involves accurately documenting findings and providing clinical/policy/regulatory support for payment determination. Essential Duties and 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. Job 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 Certification (at least one of the following is required) ? RHIA - Registered Health Information Administrator; or ? RHIT- Registered Health Information Technician; or ? CCDS – Certified Clinical Documentation Specialist; or ? CDIP – Clinical Documentation Improvement Practitioner; or ? CCS - Certified Coding Specialist; or ? CPC-H, Certified Professional Coder-H (Hospital Based); or ? CIC, Certified Inpatient Coder Experience ? 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 Apply Job!