DRG Reviewer (Onsite)

Machinify • Roseville, CA

96d • $90,000 - $110,000

About The Position

The Onsite DRG Reviewer is responsible for providing MS-DRG and APR-DRG audits services at provider locations on behalf of our clients. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. The DRG Reviewer examines medical records to validate accuracy of the UB and items billed for accurate DRG assignment along with appropriate customer payment policies applied to each case reviewed. The DRG Reviewer must be able to work independently with minimal supervision. Strong customer service skills are required. This position is an onsite audit position that requires the DRG Reviewer to live in the commutable vicinity of Nashville, TN and be able to go onsite daily to the facilities as scheduled.

Requirements

• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS).
• Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years’ experience performing DRG validation.
• Excellent oral and written communication skills.
• Comprehensive knowledge of the DRG structure and regulatory requirements.

Nice To Haves

• Previous auditing/recovery experience preferred.
• Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations.
• Solid knowledge and understanding of clinical criteria and documentation requirements to successfully substantiate code assignments.
• Subject matter expert in DRG methodologies (e.g., MS & APR).
• Demonstrated ability to work efficiently and effectively with minimal direct supervision.

Responsibilities

• Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.
• Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.
• Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.
• Maintain expert knowledge of ICD-10-CM/PCS coding conventions and rules, Official Coding Guidelines and American Hospital Association (AHA) Coding Clinic.
• Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team, meets productivity requirements.
• Ability to use multiple tools, provider systems, and different medical records systems to perform audits in a comprehensive and timely manner.
• Utilize proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and rationales.
• Assure HIPAA compliance for protected health information.
• Participate in exit interviews with the client summarizing audit findings.

Benefits

• PTO, Paid Holidays, and Volunteer Days.
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts.
• Tuition Reimbursement.
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees