DRG Validation Auditor
DRG Validation Auditor
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Salary Not Disclosed
1 Vacancy
Job Description
Position Description:
The DRG Validation Auditor is part of the DRG Validation Team and is responsible for reviewing medical records to ensure accurate coding and proper reimbursement for clinical services provided to members of Commercial and Government health plans.
The auditor reviews paid claims and identifies possible overpayments or underpayments on behalf of the client. These claims may come from various healthcare providers including acute care hospitals long-term acute care rehabilitation centers skilled nursing facilities and other care settings.
Auditors receive thorough training to understand how to review medical records apply correct coding guidelines and use client-specific documentation formats. Ongoing education is also provided to keep up with changes in coding rules audit processes and reimbursement practices.
The review process may lead to adjustments in payment for previously billed services. Auditors use their coding knowledge and critical thinking to evaluate documentation and make informed decisions.
The DRG Validation Auditor reports to a Team Leader who offers guidance and feedback. Audit performance is regularly reviewed through a quality assurance program to ensure accuracy and consistency.
FUTURE DUTIES AND RESPONSIBILITIES
Reviews inpatient medical records to validate assignment and sequencing of ICD-10 diagnosis and procedure codes discharge status codes Hospital Acquired Conditions (HACs) POA assignment and DRG assignment.
Provides a detailed rationale for every medical record review resulting in a DRG Review Results letter including supporting references.
Follows proper procedure for referral to Clinical Nurse Auditor or Physician Advisor as applicable.
Utilizes proper reference material standards and guidelines for coding.
Provides input to the Edit Development team on claims selection criteria.
Verifies data received from client and work to resolve discrepancies.
If the contract requires onsite review interacts with Providers and other personnel in a professional manner.
Follows company policies and processes completing Red Carpet timesheets payroll travel expense documents and other corporate requirements in a timely manner.
Communicates timely with Team Lead regarding illnesses appointments vacation requests changes in work schedule performance barriers and computer issues.
Complies with department standards regarding productivity and audit quality.
Performs other duties as assigned.
REQUIRED QUALIFICATIONS
Holds current AHIMA credentials (RHIT RHIA or CCS); CCS preferred
Minimum of 5 years of inpatient coding experience
Strong knowledge of ICD-10-CM/PCS coding and DRG reimbursement
Experience in training and mentoring junior coders is highly desirable
Proficient in MS-DRG and APR-DRG reimbursement methodologies
Demonstrates strong clinical validation and data analysis skills
Skilled in using Microsoft Office (Outlook Word Excel) and Windows OS
Ability to write clear well-structured narrative reviews with proper grammar and punctuation
Able to adapt to shifting priorities and meet productivity standards and deadlines
Self-directed detail-oriented and passionate about continuous learning
May be required to travel occasionally for training or on-site reviews
Skills:
- Detail-oriented
- English
- Health Insurance
- Tagalog (Philippines)
- Applications Administration
What you can expect from us:
Together as owners lets turn meaningful insights into action.
Life at CGI is rooted in ownership teamwork respect and belonging. Here youll reach your full potential because
You are invited to be an owner from day 1 as we work together to bring our Dream to life. Thats why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our companys strategy and direction.
Your work creates value. Youll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas embrace new opportunities and benefit from expansive industry and technology expertise.
Youll shape your career by joining a company built to grow and last. Youll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.
Come join our teamone of the largest IT and business consulting services firms in the world.
Employment Type
Full-Time
