DRG Auditor

JOB DESCRIPTION

Insight Global is seeking a DRG Validation Auditor for one of our clients to sit 100% remote. This person should have an extensive background in either facility-based nursing, clinical documentation, and/or inpatient coding and has a high level of understanding of reimbursement guidelines specifically an understanding of the MS-DRG, AP-DRG, and APR-DRG payment systems. This position is responsible for auditing inpatient medical records and generating high-quality recoverable claims for the benefit of our client and their clients. They are responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Below are the key responsibilities for this role:

Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.
Utilizes the clients proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
Maintains production goals set by the audit operations management team.
Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation (letter writing).
Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high-quality, high-value concepts and or process improvement, tools, etc.

MINIMUM REQUIREMENTS

5-7 years of 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.
Expert coding knowledge (DRG & ICD-10)
Registered Nurse RN (must be inpatient) WITH coding/clinical documentation certification (2 years in clinical documentation)
OR
IF NOT A NURSE: Degree in RHIM, RHIA, RHIT with medical coding degree or just CCS is fine with strong clinical knowledge