DRG Claims Auditor, Recoveries

Massachusetts General Hospital; Somerville (MA); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a detail-oriented professional to perform DRG validation and quality audits on claims. This remote role focuses on ensuring compliance with medical and reimbursement policies while identifying overpayments. The ideal candidate will leverage their extensive knowledge of coding guidelines and analytical skills to enhance audit methodologies. Join a mission-driven organization that values teamwork and integrity, and contribute to improving patient care through accurate claim processing and reimbursement. This is an exciting opportunity to engage in meaningful work that impacts the healthcare industry.

Qualifications

• 3-5 years of experience in DRG validation and claims auditing.
• Thorough knowledge of ICD-10, CPT, and HCPCS coding.

Responsibilities

• Perform DRG validation and quality audits on claims.
• Utilize expert clinical knowledge for accurate coding assignments.

Skills

ICD-10-CM/PCS coding

DRG validation

Claims auditing

Analytical skills

Communication skills

Microsoft Suite

Project management

Education

Associate's degree

Bachelor's degree

Certified Inpatient Coder (CIC)

Certified Professional Coder (CPC)

Tools

Microsoft Excel

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

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.

Qualifications

Responsibilities

1. 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.
2. 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.
3. 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. Write clearly and succinctly in various communication settings. Demonstrate excellent communication and presentation skills across multiple channels. Possess strong quantitative and analytical skills.
4. Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. View long-range trends and see the "big picture" of the business and industry.
5. Review and analyze facility and professional claims supporting MGBHP's medical and payment policies and CMS guidelines. Apply knowledge 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. Support other investigative and analytical areas with clinical expertise. Notify 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.

Additional Job Details

Qualifications

• Associate's degree required or equivalent training and experience, plus 3-5 years of related experience. Bachelor's preferred.
• Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), CPC-H, or CCS.
• Nursing license preferred.
• 5+ years of DRG validation, 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.
• Strong team player.
• Excellent project management skills.
• Familiarity with regulatory environment for financial services.
• Ability to identify complex problems, review information, develop options, and implement solutions.
• Strong work ethic and focus on quality.
• Understanding of general accounting principles.
• Ability to communicate complex topics effectively in various forums. Strong presentation and communication skills.
• Strong verbal, active listening, and written communication skills.
• Excellent interpersonal skills, including influencing others at all levels.
• Strong emotional intelligence; self-aware; receptive to feedback; disciplined in self-improvement.
• Unquestionable integrity.

Working Conditions

• This is a remote role, most US states acceptable.
• Monday through Friday, standard business hours (ET).

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement

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

Mass General Brigham Competency Framework

Our competency framework defines effective leadership behaviors, comprising ten competencies, used to evaluate performance, guide hiring, and support employee development across our system.