DRG Claims Auditor, Recoveries

Mass General Brigham Health Plan; Somerville (MA); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a detail-oriented claims auditor to perform DRG validation and quality audits. This remote role focuses on applying coding expertise to ensure compliance with medical and reimbursement policies. The ideal candidate will leverage their extensive experience in claims auditing, possess strong analytical skills, and communicate effectively across various levels. Join a dynamic team that values integrity and quality, while contributing to the enhancement of healthcare processes and outcomes. This is a fantastic opportunity for professionals looking to make a meaningful impact in the healthcare sector.

Qualifications

• 3-5 years of experience in DRG validation and claims auditing.
• Thorough knowledge of ICD-10, CPT, and Revenue Billing Codes.
• Certification such as CIC or CPC preferred.

Responsibilities

• Perform DRG validation and quality audits on claims.
• Utilize expert clinical knowledge for accurate code assignment.
• Analyze claims and provide analytical data on billing trends.

Skills

ICD-10-CM/PCS code assignment

DRG validation

Claims auditing

Analytical skills

Communication skills

Project management

Microsoft Suite

Financial services knowledge

Education

Associate's degree or equivalent training

Bachelor's degree

Certification (CIC, CPC, CPC-H, CCS)

Nursing license

Tools

Microsoft Excel

Job description

Perform DRG validation and quality audits on claims, providing coding expertise in the application of medical and reimbursement policies within the claim adjudication process. This includes document review, interpretation of state and federal mandates, applicable benefit language, coding requirements, and consideration of relevant clinical information, with a focus on overpayment identification.

Responsibilities

1. Perform DRG validation and quality audits on claims, providing coding expertise in the application of medical and reimbursement policies within the claim adjudication process through document review, interpretation of state and federal mandates, applicable benefit language, coding requirements, and consideration of relevant clinical information with a focus on overpayment identification.
2. Utilize expert clinical knowledge and judgment to identify ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance.
3. Apply solid knowledge of anatomy and physiology, diagnostic procedures, and surgical operations gained from specialized training and extensive experience with ICD-10-PCS code assignment. Communicate clearly and succinctly in various settings and styles. Demonstrate excellent communication and presentation skills across different levels and channels (oral, written, conversational). Exhibit strong quantitative and analytical skills.
4. Stay updated and compliant with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. View long-range industry trends and see the "big picture".
5. Review and analyze facility and professional claims supporting MGBHP's medical and payment policies and CMS guidelines. Apply knowledge and experience during decision-making. Complete and document audits based on established guidelines. Provide input and research claims challenged by providers.
6. Identify and provide analytical data on billing trends/issues for potential recoveries. Regularly review to enhance audit methodology and documentation. Provide clinical support to investigative and analytical areas. Identify potential audit concepts and notify the Manager of Provider Audit of leads for next steps or escalation.
7. Maintain and manage daily case review assignments with a focus on quality. Work in a high-volume, matrix-driven environment.

Qualifications:

1. Associate's degree or equivalent training and experience, plus 3-5 years of related experience; Bachelor's degree preferred.
2. Certification such as CIC, CPC, CPC-H, or CCS.
3. Nursing license preferred.
4. 5+ years of DRG validation, claims auditing, quality assurance, or recovery auditing experience required.
5. Thorough knowledge of ICD-10, ICD-10-PCS, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS, and Revenue Billing Codes.

Knowledge, Skills, and Abilities

1. Proficiency in Microsoft Suite and Excel.
2. Strong team player.
3. Excellent project management skills.
4. Familiarity with financial services regulatory environment.
5. Ability to analyze complex problems and develop solutions.
6. Strong work ethic and focus on quality.
7. Understanding of accounting principles.
8. Effective communication, tailoring messages to audiences, with strong presentation skills.
9. Excellent verbal, listening, and written communication skills.
10. Interpersonal skills and ability to influence at all organizational levels.
11. High emotional intelligence, self-awareness, feedback receptiveness, and discipline.
12. Unquestionable integrity.

Working Conditions:

1. Remote role, most US states eligible.
2. Monday to Friday, standard ET business hours.

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. We embrace diversity and are committed to equal employment opportunity for all applicants, ensuring accommodations for individuals with disabilities during the application and interview process.