DRG Reviewer - Remote

The DRG Reviewer is responsible for performing DRG payment validation (clinical/coding) reviews of medical records
and/or other documentation as defined by contract specific review criteria. This involves accurately documenting
findings and providing clinical/policy/regulatory support for payment determination.

Essential Duties and 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. • Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team. • Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and generate audit letters. • Makes recommendations for improvements to the audit system that enhance efficiency. • Assures HIPAA compliance for protected health information. • Other duties as assigned.

Job Requirements:

Education (required)
? Associate or bachelor’s degree in nursing (active/unrestricted license); or
? Associate or bachelor’s degree in health information management; or
? Work experience may be considered in lieu of formal education at leadership discretion
Certification (at least one of the following is required)
? RHIA - Registered Health Information Administrator; or
? RHIT- Registered Health Information Technician; or
? CCDS – Certified Clinical Documentation Specialist; or
? CDIP – Clinical Documentation Improvement Practitioner; or
? CCS - Certified Coding Specialist; or
? CPC-H, Certified Professional Coder-H (Hospital Based); or
? CIC, Certified Inpatient Coder
Experience
? Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required
? Inpatient Clinical Documentation Integrity experience of 2 years or more required

? Exhibits high standards for quality and attention to detail
? Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
? 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)
? Subject matter expert in ICD-10-CM/PCS coding methodologies, UHDDS definitions, Official Coding
Guidelines and AHA’s Coding Clinic Guidelines
? Demonstrates ability to work efficiently and effectively with minimal direct supervision

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