DRG Claims Auditor, Recoveries

Mass General Brigham; Somerville (MA); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a DRG Claims Auditor to perform audits and validate claims. This role requires expertise in coding and reimbursement policies, with a focus on ensuring compliance and identifying overpayments. Join a team dedicated to advancing patient care and quality assurance in a remote capacity.

Qualifications

• 3-5 years of related experience required.
• Certified Inpatient Coder (CIC) or equivalent certification needed.
• 5+ years of DRG Validation role experience.

Responsibilities

• Perform DRG validation and quality audit on claims.
• Utilize expert clinical knowledge for ICD-10-CM/PCS code assignment.
• Maintain and manage daily case review assignments.

Skills

Communication

Analytical Skills

Project Management

Team Player

Microsoft Suite

Education

Associate’s Degree

Bachelor’s Degree

Tools

Excel

Job description

Join to apply for the DRG Claims Auditor, Recoveries role at Mass General Brigham.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Perform DRG validation and quality audit 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.

This role recovers inaccurately paid DRG claims submitted by providers, with an increasing number of contracts being moved from a percentage of charge to DRG-based reimbursement.

Responsibilities

• Perform DRG validation and quality audit 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.
• Utilize expert clinical knowledge and judgement to identify the 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.
• Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment. Ability to write clearly and succinctly in a variety of communication settings and styles. Excellent communication and presentation skills across various levels and through multiple channels (oral, written, conversational). Strong quantitative and analytical skills.
• Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. Ability to view the long-range trends and cycles of the business and industry and see the “big picture.”
• Review and analyze facility and professional claims in support of MGBHP's medical and payment policies and CMS guidelines. Apply knowledge and experience during decision-making process. Complete and document audits based on established guidelines. Provide input on and research of claims challenged by the providers.
• Identify and provide analytical data on billing trends/issues for potential areas of recoveries. Regularly reviews to identify enhancement to the audit methodology and documentation requirements. Provide clinical support and expertise to the other investigative and analytical areas. Identify potential audit concepts and notify Manager of Provider Audit of any leads, in support of next steps or escalation to outside agencies.
• Maintain and manage daily case review assignments, with a high emphasis on quality. Work in a high-volume production environment that is matrix driven.

Qualifications

• Associate’s degree required or the equivalent combination of training and experience, plus 3-5 years of related experience. Bachelor’s degree preferred.
• Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), CPC-H (hospital) or CCS (Certified Coding Specialist).
• Nursing license preferred.
• 5+ years of DRG Validation role performing DRG claims auditing, quality assurance, or recovery auditing required.
• Thorough knowledge of ICD-10, ICD-10-PCS, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS, and Revenue Billing Codes.

Knowledge, Skills, And Abilities

• Superior Microsoft Suite and Excel Skills required.
• Being a strong team player.
• Excellent project management skills.
• Familiarity with the regulatory environment for financial services.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Strong work ethic and focus on quality work.
• Understanding of general accounting principles.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
• Strong verbal, active listening, and written communication skills required.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.

Working Conditions

• This is a remote role that can be done from most US states.
• Monday through Friday, standard business hours (ET) are required.

Additional Details

• Remote work from most US states.
• Work hours: 40 hours/week, Day shift, Monday-Friday (ET).
• Employee type: Regular, Full-time.
• Location: 399 Revolution Drive.

EEO Statement

Mass General Brigham is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, or other protected status. Reasonable accommodations are available for individuals with disabilities. Contact Human Resources at (857)-282-7642 for accommodations.