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Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III
Location
United States
Posted
33 days ago
Salary
$65.3K - $142.3K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III
Excellus BlueCross BlueShield
Role Description The Payment Integrity DRG Coding & Clinical Validation Analyst position has an extensive background in acute facility-based clinical documentation, and/or inpatient coding and has a high level of understanding of the current MS-DRG, and APR-DRG payment systems. This position is responsible for reviewing medical records for appropriate provider documentation to support the principal diagnosis, co-morbidities, complications, secondary diagnosis, surgical procedures, POA indicators to validate coding and DRG assignment accuracy, ensuring the physician documentation supports the hospital coded data. Qualifications - Associate or bachelor’s 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. - Intermediate knowledge of PC, software, auditing tools and claims processing systems. Requirements - Level I: - Analyzes and audits acute inpatient claims. - Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. - 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 Management. - Consistently demonstrates high standards of integrity. - Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. - Regular and reliable attendance is expected and required. - Performs other functions as assigned by management. - Level II (in addition to Level I Accountabilities): - Performs complex audits or projects with minimal direction or oversight. - Acts as an expert in reviewing medical coding and medical record review. - Supports leadership in projects related to divisional/departmental strategies and initiatives. - Participates and represents in audits, payment methodologies, contractual agreements. - Serves as a mentor to new hires. - Demonstrates ability to participate and represent department on internal/external committees. - Level III (in addition to Level II Accountabilities): - Provides expertise in developing data criteria for audits. - Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members. - Serves as an expert and resource for escalations. - Provides backup support for Management as necessary. Benefits - Participation in group health and/or dental insurance. - Retirement plan. - Wellness program. - Paid time away from work. - Paid holidays. Compensation Range(s) - Level I: Grade E4: Minimum: $65,346 - Maximum: $117,622 - Level II: Grade E5: Minimum: $71,880 - Maximum: $129,384 - Level III: Grade E6: Minimum: $79,068 - Maximum: $142,322
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