Remote DRG / Clinical Validation Auditor (Work from home)
The Auditor, DRG Coding & Clinical Validation position has an extensive background in nursing, inpatient coding and reimbursement guidelines and specifically has a solid understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. This position is responsible for auditing client data and generating high quality recoverable claims for the benefit of Cotiviti and our clients. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered. Primarily responsible for auditing efforts by executing projects assigned by the Director, Audit Operations or Manager, Audit Operations. Displays professional skepticism that enhances the work performed in order to achieves success in position.
Identifies and Enters Claims. Integrates medical chart coding principles and objectivity in performance of medical audit activities. Draws on advanced ICD-9 and ICD-10 coding expertise and industry knowledge to substantiate conclusions. Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues, and quality concerns.
Effectively Utilizes Audit Tools. Utilizes with advanced proficiency, Cotiviti and client tools required to perform duties. Enters the claim into Cotiviti system accurately and in accordance with standard procedures. Updates current reports, develops and runs custom queries and validates accuracy of current reports used. Makes determinations based on prior knowledge, experience of client contract terms with the likelihood of recovery acceptance.
Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals and quality standards set by the audit for the auditing concept. Audits against the expected level of quality and quantity (i.e. hit rate, # claims written, ID per hour).
Meets or Exceed Standards/Guidelines for Quality. Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
Prepares Responses to Client Disputes. Provides independent verification of claims validation, insurance or employer validation in a concise written manner.
Reviews Provider Contracts. Demonstrates high level of expertise in researching requirements necessary to make recommendations on client contracts to fit projects within standard reports such as medical policies and state and federal statutes.
Identifies New Claim Types. Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high quality, high value concept and or process improvement, tools, etc.
Recommends New Concepts and Processes. Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience. Suggests, develops and implements new ideas, approaches and or technological improvements that will support and enhance audit production, communication and client satisfaction. Evaluate information and draw logical conclusions. Collaborates with Data Services in developing new reports.
Education & Work Experience
Associates Degree or equivalent relevant experience required. Bachelor’s degree in Nursing, Healthcare Economics, Health Information Management, and/or Business, preferred, or 5 – 7 years’ experience (experience in any of the following: claims auditing/quality assurance/recovery auditing – ideally in a DRG / Clinical Validation Audit setting or hospital environment) strongly preferred.
Strongly preferred Nursing education (ASN, BSN, or MSN); active, unrestricted license.
Clinical /Nursing experience in an inpatient setting is a plus.
Coding certification required and maintained as a condition of employment. (CCS, or CIC, preferred). Candidates who hold a CCDS or CPC will also be given consideration but will need to obtain an inpatient coding certification within 6 months of their hire date with the company.
5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes.
Requires working knowledge of and applicable industry based standards.
Proficiency in Word, Access, Excel and other applications.
Excellent written and verbal communication skills.
Flexible to travel to one of our offices for the first full week of work to focus on training (company paid travel and expenses)
High speed internet connection required
Ability to work from home in a production environment
Ability to meet or exceed both production & quality metrics assigned by the company, insuring all rules and processes are followed.
Alerts manager / team lead of systems issues or other issues impacting productivity.