Senior Claims Auditor - DRG
Skills
About the Role
You will conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement. You'll apply your expert knowledge of coding guidelines and use industry-leading tools to maximize overpayment identification. You'll craft clear, concise, and well-supported audit findings backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations, and use advanced DRG encoder tools to drive efficiency and accuracy. You'll meet or exceed quality and productivity standards, including strong uphold rates for appeals, while staying ahead of industry trends, coding updates, and compliance regulations. You'll adhere to HIPAA and company policies to ensure data security and regulatory compliance, and maintain superior knowledge of coding guideline changes, reimbursement trends, and health payment policy language.
Requirements
- 6+ years experience performing MS-DRG and APR-DRG reviews for a Payment Integrity vendor or Payer required
- An active certified coder credential (e.g., CIC, CPC, CCS, RHIA, or RHIT) required
- CCS (Certified Coding Specialist) credential highly preferred
- Advanced expertise in ICD-10-CM/PCS coding and ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding
- Ability to prepare clear, concise, and well-supported audit findings referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines
- Self-motivated and able to work independently in a remote environment while maintaining high performance
- Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously
- RHIA or RHIT credential, Associate's Degree in Health Information Management, Nursing, or related field preferred
- Inpatient audits for case rate and per diem preferred
- Experience working in a start-up or high-growth company environment
- Familiarity with working with a diverse, global team
- Excellent computer skills and familiarity with a Mac
Responsibilities
- Conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement
- Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications
- Craft clear, concise, and well-supported audit findings backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations
- Utilize advanced DRG encoder tools to drive efficiency and accuracy in audits
- Meet or exceed company quality and productivity standards, including strong uphold rates for appeals
- Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge
- Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance
- Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language
Benefits
- Fully remote opportunity with about 5% travel
- Medical, dental, vision, life, disability insurance
- Employee Assistance Program
- 401K retirement plan with company match
- Flexible spending and health savings account
- Paid Time Off + company holidays
- Up to 14 weeks of paid parental leave
- Pet insurance