Senior Inpatient Coding Auditor

DME Service Solutions; Philippines; On-site; PHP 350,000 - 650,000; Full time

Job summary

DME Service Solutions in the Philippines seeks a Payment Integrity DRG Coding & Clinical Validation Analyst to review medical records, validate principal diagnosis, co-morbidities, and POA indicators to ensure accurate coding and DRG assignment.

The role requires extensive inpatient coding experience, knowledge of MS-DRG and APR-DRG, and the ability to work independently while adhering to coding guidelines and privacy policies.

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 to be maintained as a condition of employment: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC
• Intermediate analytical and problem-solving skills
• Keeps abreast of latest trends related to business analysis

Responsibilities

• Analyze and audit acute inpatient claims
• Review medical records and integrate medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
• Draw on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
• Perform work independently and adhere to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates
• Establish national and best practice benchmarks and measure performance against benchmarks
• Ensure accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform
• Manage case volumes and review/audit schedules, prioritizing case load as assigned by management
• Maintain high regard for member privacy in accordance with corporate privacy policies and procedures

Skills

Analytical skills

Problem-solving skills

Business analysis awareness

Education

Bachelor's degree in Health Information Management or Nursing

Job description

About the role

The Payment Integrity DRG Coding & Clinical Validation Analyst reviews medical records for appropriate provider documentation to support the principal diagnosis, co-morbidities, complications, secondary diagnosis, surgical procedures, and POA indicators to validate coding and DRG assignment accuracy, ensuring the physician documentation supports the hospital coded data. The Analyst has an extensive background in acute facility-based clinical documentation and/or inpatient coding with a high level of understanding of the current MS-DRG and APR-DRG payment systems.

Key responsibilities

• Analyze and audit acute inpatient claims
• Review medical records and integrate medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
• Draw on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
• Perform work independently and adhere to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates
• Establish national and best practice benchmarks and measure performance against benchmarks
• Ensure accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform
• Manage case volumes and review/audit schedules, prioritizing case load as assigned by management
• Maintain high regard for member privacy in accordance with corporate privacy policies and procedures

About you

• 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 to be maintained as a condition of employment: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC
• Intermediate analytical and problem-solving skills
• Keeps abreast of latest trends related to business analysis