DRG Auditor

ClaimLogiq - Alpharetta, GA

DRG Auditor needed to review commercial insurance claims for accuracy of codes and validation of DRGs on a prepayment and post-payment basis. The position involves review of inpatient medical records to: collect data and to ensure appropriate billing of that data. Includes: validation of the admission order, discharge disposition, procedure codes, diagnosis codes and their sequencing.

2+ years performing DRG validation and audits
Thorough understanding of ICD-9 and ICD-10
Applied knowledge of CMS rules and regulations
Ability to prepare a detailed rationale for the medical DRG review
Official coding guidelines
Applied knowledge AHA coding clinics
Compliance with department standards regarding productivity and audit accuracy
Advanced knowledge of EMR and computer applications

Duties and Responsibilities:
Review the medical records for diagnoses and procedures and compare it to the claims submitted by facilities to assure correct reimbursement with savings before payment
Verify that primary diagnosis is the reason for admission
Verify that all complicating conditions (MCCs/CCs) are appropriately documented in medical records and meets criteria of secondary diagnoses
Verify that the sequencing of the diagnostic and procedure codes are appropriately assigned
Verify that the procedure codes are correct based on the operative report
Verify that the DRG grouping is appropriate based on documented diagnoses and procedures
Verify the correct discharge disposition/status of the patient as it may affect the reimbursement in some cases