Analyzes and audits acute inpatient claims. 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.
Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge –DRG &ICD 10.
Establishes national and best practice benchmarks and measures performance against benchmarks.
Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
Manages case volumes and review/audit schedules, prioritizing case load as assigned by EHP Management.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Qualifications:
Degree in health information management (RHIA or RHIT) or a Nursing Degree.
Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting.
Three (3) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology
Coding Certification is to be maintained as a condition of employment of one of the following: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC.
Intermediate analytical and problem-solving skills; as well as keeps abreast of latest trends related to business analysis.
Job details are sourced from the employer's original posting.
