Senior DRG Auditor (Disputes)

Skills

About the Role

You will join a dynamic Payment Integrity team, conducting comprehensive MS-DRG and APR-DRG coding reviews to ensure the accuracy of claims and maximize overpayment identification. You'll apply your CCS credential and superior knowledge of ICD-10-CM/PCS coding guidelines to deliver deep analytical work. You'll craft clear, concise, and well-supported audit findings backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations, using 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 and compliance regulations, and adhering to HIPAA and company policies.

Requirements

• 6+ years experience of performing MS-DRG and ARP-DRG reviews for a Payment Integrity vendor or Payer required
• Experience with provider appeals/dispute reviews required
• Advanced expertise in ICD-10-CM/PCS coding and ability to assess complex clinical information, validate diagnosis code assignments, and identify discrepancies such as coding errors or upcoding
• Prepares clear, concise, and well-supported audit findings referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines
• An active certified coder credential (e.g., CIC, CPC, CCS, RHIA, or RHIT) required
• CCS (Certified Coding Specialist) credential highly preferred
• 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
• Excellent written and verbal communication skills, strong analytical skills, and attention to detail
• RHIA or RHIT credential, Associate's Degree in Health Information Management, Nursing, or related field preferred
• Inpatient audits for case rate and per diem
• Experience working in a start-up or high-growth company environment
• Familiarity with working with a diverse, global team of talent
• Excellent computer skills and familiarity with a Mac
• Payment Integrity audit experience preferred

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, and 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