DRG Validator

gmh; Atlanta (GA); Vor Ort; USD 65.000 - 90.000; Vollzeit

Zusammenfassung

Grady Health System in Atlanta seeks a DRG Validator to review inpatient coded records per UHDDS, validate ICD-10-CM/PCS assignments, and collaborate with CDI for SOI/ROM assessment. The role requires strong knowledge of MS-DRG/APR-DRG and AHA guidelines, with attention to accuracy and documentation quality.

You will perform chart reviews, assist in pre-bill reviews, and support education initiatives with Coding and CDI teams while leveraging SMART tools for data insights.

Qualifikationen

• 2 years auditing experience or strong training background in coding and reimbursement.
• 5 years progressive inpatient coding in an acute care hospital and ICD-10-CM/PCS review.
• Experience with Epic System is a plus.

Aufgaben

• Performs daily coding reviews for HACs, PSIs and focused DRGs on inpatient records identified by SMART to validate ICD-10-CM/PCS codes and POA assignment.
• Sends notifications to Quality Department for Quality Level reviews on cases where PSI/HAC indicators align with documentation.
• Reviews selected records to validate secondary diagnoses and procedures for compliance with reporting requirements.
• Writes concise rationale to support audit findings and DRGReview letters with applicable guidelines.
• Evaluates clinical documentation quality to identify incomplete or ambiguous inpatient documentation affecting DRG assignment.
• Using SMART Tool, performs data analysis to identify coding trends and informs CDI opportunities.

Kenntnisse

Auditing experience

Inpatient coding

Coding & reimbursement

Ausbildung

BA Health Administration

Tools

Epic System

Jobbeschreibung

Job Summary

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary

The Diagnosis Related Group (DRG) Validator, is responsible for reviewing inpatient coded records records in accordance with Uniform Hospital Discharge Data Set (UHDDS) Definitions to validate an inpatient admit order, assignment of and sequencing of ICD-10-CM/PCS principal and secondary diagnoses, principal and secondary procedures, the discharge disposition codes and the DRG Assignment. Solid knowledge of MS-DRG, APR-DRG (SOI/ROM), Coding Guidelines, American Hospital Association (AHA) Coding Clinic and Present on Admission (POA) Indicator Guidelines. All HACs, PSIs and focused MS-DRGs are identified by PWC SMART Application. Collaborates with Quality Department for 2nd Level quality review of all Hospital Acquired Conditions (HACs) and selected AHRQ Patient Safety Indicators (PSIs). Works with Clinical Documentation Improvement (CDI) Manager, upon request will performs 2nd level review of identified cases for appropriate assignment of Severity of Illness (SOI) and Risk of Mortality (ROM) utilizing the APR-DRG. Performs chart review for DRG Claim Review Requests and determine correctness of original vs. recommended MS-DRG. The DRG Validator assists the Coding Manager with identifying coding trends for education based on audit findings. As needed, performs inpatient coding of accounts.

RESPONSIBILITIES

• Performs daily coding reviews for HACs, selected PSIs and focused DRGs on inpatient records identified by SMART to validate the assigned ICD-10 CM/PCS Codes and Present of Admission (POA) assignment.
• Send notifications to the Quality Department (Quality Reviewer) to conduct a Quality Level review on cases in which the PSI/HAC Diagnosis and/or POA indicators are in alignment with documentation.
• Reviews selected records, validating secondary diagnoses and procedures to ensure compliance with all reporting requirements.
• Ability to write concise rationale to support audit findings and DRG Claim Review Appeal letters, referencing applicable official guidelines, when applicable.
• Evaluates the quality of clinical documentation to identify incomplete or ambiguous documentation for inpatient encounters that impact the code selection and resulting DRG assignment and reimbursement.
• Utilizing SMART Tool, ability to perform data analysis and identify trends for Coding/CDI opportunities and provide feedback to assure coding uniformity, consistency and accuracy with ICD-10-CM/PCS.
• Works closely with the Clinical Documentation Improvement Manager in pre-bill review of Mortality charts and Hospital Acquired Conditions (HACs), and specific diagnosis or DRG's as assigned.
• Collaborates with the Coding Vendor to provide input for development of educational areas for inpatient coding involving both internal and external training.
• Works jointly with Independent Coding Auditor regarding recommendations for revisions to diagnoses and/or procedures, queries and HIM DRG spreadsheet.
• Works with Executive Director of HIM and Corporate Coding & Reimbursement Manager to develop process improvements to maintain data quality.
• As needed, assist with coding of accounts.
• Completes special projects as assigned, other duties as assigned.

QUALIFICATIONS

• 2 years Auditing experience or strong training background in coding and reimbursement.
• 5 years Progressive inpatient coding in an acute care hospital and coding review experience in ICD-10-CM/PCS.
• Claims processing and/or data management responsibilities, a plus. Experience with Epic System, a plus

EDUCATION

BA Health Administration

CERTIFICATIONS

• MGNT-Certified Coding Specialist - AHIMA - American Health Information Management Association
• Registered Health Information Technician - AHIMA - American Health Information Management Association
• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)

Core Competencies

1. Patient-Centered Care - Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2. Integrity & Accountability - Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3. Collaboration & Teamwork - Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication - Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5. Respect & Inclusion -