Lead, DRG Coding/Validation (RN)

Molina Healthcare•Long Beach, CA

About The Position

Job Summary Provides lead level support developing diagnosis-related group (DRG) validation tools and process improvements - ensuring that member medical claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10 and/or CPT codes, and accuracy of DRG or ambulatory payment classification (APC) assignments. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Develops diagnosis-related group (DRG) validation tools to build workflow processes and training, auditing and production management resources. • Identifies potential claims outside of current concepts where additional opportunities may be available. Suggests and develops high-quality, high-value concepts and or process improvements, tools, etc. • Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. • Audits inpatient medical records and generates high-quality claims payment to ensure payment integrity. • Performs clinical reviews of medical records and other utilization management documentation to evaluate issues of coding and DRG assignment accuracy. • Collaborates and/or leads special projects. • Influences and engages team members across functional teams. • Facilitates and provides support to other team members in development and training. • Develops and maintains job aids to ensure accuracy. • Escalates claims to medical directors, health plans and claims teams, and collaborates directly with a variety of leaders throughout the organization. • Facilitates updates or changes to ensure coding guidelines are established and followed within the health Information management (HIM) department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines. • Ensures care management and Medicaid guidelines around multiple procedure payment reductions and other mandated pricing methodologies are implemented and followed. • Supports the development of auditing rules within software components to meet care management regulatory mandates. • Utilizes Molina proprietary auditing systems with a high-level of proficiency to make audit determinations, generate audit letters and train team members.

Requirements

At least 3 years clinical nursing experience in claims auditing, quality assurance, recovery auditing, DRG/clinical validation, utilization review and/or medical claims review, or equivalent combination of relevant education and experience.
Registered Nurse (RN). License must be active and unrestricted in the state of practice.
Experience 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.
Strong knowledge in coding: DRG, ICD-10, CPT, HCPCS codes.
Excellent verbal and written communication skills.
Extensive background in either facility-based nursing and/or inpatient coding, and deep understanding of reimbursement guidelines.
Ability to work cross-collaboratively across a highly matrixed organization.
Strong verbal and written communication skills.
Microsoft Office suite proficiency (including Excel), and applicable software program(s) proficiency.

Nice To Haves

Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
Claims auditing, quality assurance, or recovery auditing, ideally in DRG/clinical validation.
Training and education experience.

Responsibilities

Develops diagnosis-related group (DRG) validation tools to build workflow processes and training, auditing and production management resources.
Identifies potential claims outside of current concepts where additional opportunities may be available. Suggests and develops high-quality, high-value concepts and or process improvements, tools, etc.
Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.
Audits inpatient medical records and generates high-quality claims payment to ensure payment integrity.
Performs clinical reviews of medical records and other utilization management documentation to evaluate issues of coding and DRG assignment accuracy.
Collaborates and/or leads special projects.
Influences and engages team members across functional teams.
Facilitates and provides support to other team members in development and training.
Develops and maintains job aids to ensure accuracy.
Escalates claims to medical directors, health plans and claims teams, and collaborates directly with a variety of leaders throughout the organization.
Facilitates updates or changes to ensure coding guidelines are established and followed within the health Information management (HIM) department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.
Ensures care management and Medicaid guidelines around multiple procedure payment reductions and other mandated pricing methodologies are implemented and followed.
Supports the development of auditing rules within software components to meet care management regulatory mandates.
Utilizes Molina proprietary auditing systems with a high-level of proficiency to make audit determinations, generate audit letters and train team members.