DRG Audit Coordinator
To review the overall accuracy, integrity and quality of patient data and bills that are submitted for payment and subsequently revised by payer. Coordinates review of all payer DRG/SOI findings with other contributing departments throughout the Hospital. Performs review of the medical record and the assigned DRG Coding by examining medical record documentation to validate the conditions that were documented in the medical record, the ICD-10-CM/PCS code assignments and determining the accuracy of DRG assignment. Works closely with the HIM Coding Department to prepare, draft, submit and defend all coding appeals with supporting documentation from the medical record, coding guidelines and other authorities as applicable. Prepares, drafts, submits and defends appeals at all levels by using documentation in the medical record, including compilation of documentation, timely and accurate release of information, timely coordination of appeals, and response within all associated timelines and deadlines through the appeals process. Tracks and trends the status of all payer DRG validations by maintenance of the database. Ensures each step of the process is documented and all steps of the process are performed within the required timeframes. Provides reporting of trends and root causes of payer DRG downgrades to Revenue Integrity Director. Develops and maintains a structured standardized process for facilitating appeals at all levels. Works with outside vendors engaged for DRG Validation projects, including review of all findings identified by the outside vendors. Provides ongoing education regarding opportunities to improve outcomes and trends. Works collaboratively with the other leaders and supervisors to achieve department and hospital-wide quality, safety and financial goals. Performs other duties as assigned.
Bachelor's Degree in Health Information Management preferred. Registration as Health Information Administrator (RHIA) or Health Information Technician (RHIT) or certification by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a Certified Coding specialist (CCS), Certified Professional Coder (CPC) or Professional Coder-Hospital (CPC-H). Must have excellent verbal and written communication skills. Must have strong computer, verbal and written communication skills.
Minimum Work Experience
Three or more years coding experience in a health related setting.
RHIA or RHIT required, RHIT with CCS preferred. Required to have a minimum of three (3) years current & continuous acute care hospital Inpatient coding and DRG analysis with advanced knowledge of current codes sets, guidelines and principles. Demonstrates superior coding and critical thinking skills with ability to solve problems appropriately using knowledge, and current policies/procedures/guidelines and regulations. Technically competent and fluent knowledge in navigation of electronic medical record applications, coding decision support tools, including encoders, abstracting & billing systems, electronic medical records (used as coding source documents), and other associated computer applications required. Proficiency in computer assisted coding/CDI tools, automated coding work flow process and management of coded data integrity highly desired. Experience using Microsoft Office applications (excel, word) required.
Ability to remain focused, work well independently and productively with minimal guidance and without direct supervision. Must have sharp analytical and critical thinking skills, must be highly detail oriented, have strong organizational, writing, interpersonal and communication skills with ability to maintain confidentiality, create positive relationships; energetic, flexible, goal and team oriented. Ability to provide excellent customer service routinely in all types of interactions with all individuals. Demonstrated coding knowledge and proficiency is required through on-site evaluation prior to hire. Skills assessment required with demonstrated ability to easily articulate knowledge of coding guidelines and procedures.
[Mississippi, United States] Coders, Health Information Registered Health Information Administrator (RHIA) or Registered Health Information Technologist (RHIT) required, Certified Coding Specialist (CCS) preferred. ICD-10-CM/PCS training completed.