DRG Nurse Auditor

UHS•Richmond, VA

About The Position

The Atlantic Region CBO is seeking a dynamic and talented DRG Nurse Auditor with clinical case management experience to be responsible for analyzing clinical claim denials, drafting detailed appeal letters, evaluating clinical level of care, and the review of denial trends. Key Responsibilities include: Perform DRG (Diagnosis Related Group) validation reviews in response to audits from third party payers. Review audit findings letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying payer clinical/coding rationale. Analyze medical records to obtain supporting clinical documentation for billed diagnosis codes. Communicate findings to third party payers in detailed appeal letters to prevent downgrade payment recoveries. Make decisions to update DRGs or remove or add to billed diagnose codes based on clinical reviews. Call third party payers and physician offices as needed to obtain additional clinical details. Identify audit trends and provide feedback to management and to UHS acute care facilities. Adherence to all applicable laws, regulations and guidelines. Other duties as assigned.

Requirements

RN or LPN licensure in good standing is required.
Three to five years of experience is preferred
Working knowledge of coding regulations including ICD-10, DRGs, and HCPCs.
Strong Microsoft Office skills (Excel, Word, Outlook)
Customer focused both internally and externally, strong attention to detail, the ability to multi-task.
Excellent written and oral communication skills are required.

Nice To Haves

BSN degree preferred
CPC, CCS or other coding credentials preferred, but not required
CDI Experience is preferred.
CCDS certification is preferred.
Experience working in Patient Financial Services and an understanding of the Revenue Cycle from beginning to end is preferred.
Experience working in case management or audit with technical denials is preferred.

Responsibilities

Perform DRG (Diagnosis Related Group) validation reviews in response to audits from third party payers.
Review audit findings letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying payer clinical/coding rationale.
Analyze medical records to obtain supporting clinical documentation for billed diagnosis codes.
Communicate findings to third party payers in detailed appeal letters to prevent downgrade payment recoveries.
Make decisions to update DRGs or remove or add to billed diagnose codes based on clinical reviews.
Call third party payers and physician offices as needed to obtain additional clinical details.
Identify audit trends and provide feedback to management and to UHS acute care facilities.
Adherence to all applicable laws, regulations and guidelines.
Other duties as assigned.