DRG Coding & Clinical Validation Specialist

Capital District Physicians Health Plan Inc; City of Rochester (NY); Hybrid; USD 65,346 - 142,322; Full time

Job summary

CDPHP is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to review inpatient records and validate DRG assignments, ensuring the physician documentation supports principal diagnosis, co-morbidities, procedures, and POA indicators.

This role progresses from Level I to Level III responsibilities, conducts complex audits, mentors staff, and partners with cross-functional teams to improve payment accuracy and regulatory compliance across the health plan.

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.

Responsibilities

• Audit acute inpatient claims and ensure coding accuracy.
• Adhere to official coding guidelines, coding clinic determinations, and CMS and other regulatory guidelines.
• Establish national and best practice benchmarks and measure performance against benchmarks.
• Ensure accurate payment by using DRG grouper, encoder, and claims processing platform.
• Manage case volumes and audit schedules as assigned by Management.
• Mentor new hires and participate in cross-functional audits and initiatives.
• Provide leadership in data criteria development for audits and act as a subject matter expert.

Skills

ICD-10 coding

DRG coding

Auditing

Analytical skills

Problem-solving

Education

RHIA/RHIT or Nursing Degree

Tools

DRG encoder

Claims processing systems

Auditing tools

Job description

CDPHP is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to review inpatient records and validate DRG assignments, ensuring the physician documentation supports principal diagnosis, co-morbidities, procedures, and POA indicators.

This role progresses from Level I to Level III responsibilities, conducts complex audits, mentors staff, and partners with cross-functional teams to improve payment accuracy and regulatory compliance across the health plan.