Senior DRG Audit SME

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Requirements:

• Associates or Bachelor's degree in Nursing
• Associate or Bachelor's degree in Health Information Management (RHIA or RHIT)
• Equivalent experience of 5+ years experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting.
• RHIA or RHIT
• Inpatient Coding Credential - CCS or CIC preferred
• 5 -10 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.
• Experience with outpatient coding (CPT, HCPCS, and modifiers)
• Experience developing audit selection criteria to identify DRG coding errors and overpayments.
• Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
• Requires expert coding knowledge - DRG & ICD-10.
• Requires working knowledge of applicable industry-based standards.
• Excellent written and verbal communication skills.
• Proficiency in the use of EMR’s and encoders.

Responsibilities:

• Conduct comprehensive DRG validation audits of inpatient medical records to ensure accurate coding, adherence to coding guidelines, and compliance with regulatory requirements
• Serve as an inpatient coding expert and resource for the coding teams and other departments; ensuring that information is accurate and current, meeting professional coding standards.
• Develop and refine coding policies and procedures in collaboration with the HIM team.
• Quality Review - Monitors and audits inpatient and/or outpatient client accounts across the system, looking at facility coding for inpatient and/or outpatient accounts.
• Edits/Denials/Coding - Assists with edits, denials and appeals.
• Reporting - Assists with the creation of various documents and reports as requested. Immediately provides reports related to compliance risks when requested.
• Payment integrity- Assists with other audit types as needed in support of product, audit opportunities, and concept development.
• Remain updated with the latest coding guidelines and regulations
• Achieve the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation
• Identify New Claim Types/Overpayment Opportunities.
• Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high-quality, high-value concepts and or process improvement, tools, etc.