DRG Validation Auditor -Contractor

AAPC; Salt Lake City (UT); Remote; USD 75,000 - 100,000; Full time

Job summary

AAPC is seeking a DRG validation auditor to join their remote team, focusing on improving medical coding practices and reimbursement accuracy in pediatric healthcare. The ideal candidate will have robust auditing experience, particularly in coding-related denials and must possess relevant certifications.

Qualifications

• Extensive knowledge of healthcare coding and auditing.
• 5 years of experience in DRG and APR-DRG auditing.
• Strong background in pediatric healthcare services.

Responsibilities

• Validate ICD-10-CM, ICD-10-PCS, and DRG appropriateness.
• Audit inpatient claims for proper DRG coding.
• Identify and resolve complex coding discrepancies.

Skills

Attention to detail

Analytical skills

Critical thinking

Communication

Organizational skills

Education

RHIA/RHIT or CCS certification

CPMA, CIC, or COC certification

Tools

Coding software

Electronic health record systems

Job description

This is a remote role

We are seeking a DRG validation auditor specializing in coding-related denials, reimbursement audits, and clinical documentation improvement. This Auditor will be part of a team of clinicians, engineers, product managers, and other domain experts who are applying state-of-the-art machine learning software to improve the data quality and medical coding practices of providers. This is an opportunity to help inform the next generation in auditing software as well as to work in a dynamic environment with a high-performing team.

The ideal candidate for this position needs to have both an inpatient and outpatient coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient MS-DRG/APR-DRG, and Outpatient CPT-4/HCPCS coding and auditing, with a strong focus on pediatric healthcare services and coding accuracy and payer claim processing.

Job Duties:

• Validate the accuracy of ICD-10-CM, ICD-10-PCS, and DRG and APR group appropriateness, CPT and HCPCS inpatient patient and outpatient facility claims.
• Auditing inpatient claims to identify DRG codes that may have been over-assigned, ensuring accurate reimbursement aligned with regulatory and contractual guidelines.
• Identify and resolve complex coding discrepancies.
• Communicate complex coding findings to project lead and other cross functional teams.
• Be responsible and accountable for maintaining confidentiality, integrity, and availability of protected health information. Follow HIPAA security policies and procedures affecting your job, and report any suspected or actual violation or breach.

Minimum Requirements:

• Extensive knowledge of healthcare industry and experience in and around coding, billing, auditing, compliance and reimbursement for Inpatient and Outpatient facility.
• Must have extensive pediatric inpatient facility experience.
• 5 years of auditing facility inpatient and outpatient services with DRG and APR-DRG as well as familiarity with clinical documentation improvement practices.
• Extensive knowledge of current Official Coding Guidelines and Coding Clinic citations.
• Strong background in cost reduction strategies by ensuring correct claims payment and appropriate diagnosis-related group (DRG) assignment including familiarity with inpatient denial coding systems (e.g. CARC codes).
• Proficiency in coding software, electronic health record systems and familiar with how AI tools can assist in identifying over/under-assigned DRGs.
• High level proficiency in anatomy, physiology, disease process, and pharmacology.
• Detail oriented and deadline driven attitude.
• Ability to think critically and determine the best method for resolving challenges.
• Strong organizational skills, a strong sense of accountability, a proactive work ethic.

Certification Requirements:

• RHIA, RHIT, or CCS from AHIMA and/or CPMA, CIC, COC from AAPC
  

Attributes:

Humble - Learns, adapts, and improves relentlessly. Seeks feedback without insecurity and implements coaching. Recognizes others' contributions gratefully. Approaches work and relationships with an abundance mentality. Places the needs of others above self.

Supportive - Empowers and uplifts others. Listen actively and responds with empathy and understanding. Prioritizes well-being and growth of team members and customers ahead of own interest. Faces challenges together, believing in collective strength and unity.

Driven - Self-starts and stays highly motivated to achieve ambitious goals. Shares contagious energy and enthusiasm liberally. Takes initiative without always being directed. Demonstrates confidence in decision-making and effectively balances autonomy and authority with accountability.

Transparent - Aligned with a culture of openness, integrity, and trustworthiness. Follows through on commitments to internal and external parties. Maintains strict accountability and values the trust placed in them by others.

Innovative - Entrepreneurial spirit with a scrappy mentality. Dreams big, sees opportunity, pursues full potential, and finds ways to accomplish the impossible. Rolls up sleeves and does real work. Works quickly, intelligently, and flexibly.

Expected Work Volumes

• Work volumes will vary depending upon projects

AAPC Services is an Equal Opportunity Employer. This company does not and will not discriminate in employment and personnel practices on the basis of race, sex, age, handicap, religion, national origin or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above listed items.

We are an Equal Opportunity Employer. This company does not and will not discriminate in employment and personnel practices on the basis of race, sex, age, disability, religion, national origin, or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above-listed items.