The primary purpose of this position is to conduct reviews of DRG claims for coding accuracy and correct DRG assignment
- Reviews all cases decoding all diagnosis and procedures and comparing to bill summary to assure charges are in appropriate areas.
- Verifies that primary diagnosis is the reason for admission.
- Verifies that all complicating conditions are appropriate and documented in medical records
- Verifies that DRG grouping is appropriate based on documented diagnosis and procedures.
- Verifies accuracy of original claim allowance utilizing client’s base rates, relative weights, and other reimbursement exceptions
- Identifies in writing any changes to the coding or DRG with the medical facility and obtain a signed agreement.
- Maintains open communication.
- All other duties as assigned.
Required Skills
- Diploma in nursing required (Associate or Bachelor’s degree in nursing preferred).
- Active unrestricted nursing license in state of employment.
- Must have at least 3 years of clinical nursing experience.
- NICU audit experience preferred.
- UM/Insurance appeals/denials experience preferred
- DRG coding or Clinical documentation experience required.
- Coding Certification preferred. Must be enrolled or working towards coding certification within 2 years of employment.
- Must be proficient in Microsoft Word and Microsoft Outlook.
- Experience with electronic medical records systems preferred.
- Proficient typing skills.
- Must be detailed oriented.
- Must be able to successfully complete any required pre-employment testing.
