Payment Integrity: DRG Coding & Clinical Validation Analyst

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

Job summary

CDPHP in Albany, NY is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with deep ICD-10/DRG expertise to review acute inpatient records and validate DRG assignments. You will audit claims, ensure CMS guideline compliance, and mentor staff.

The role supports data quality and payment integrity, with remote work possible case-by-case. Qualified candidates typically hold RHIA/RHIT or nursing degrees and have 3+ years in DRG/ICD-10 auditing, plus strong analytical skills and

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 validate DRG accuracy.
• Adhere to official coding guidelines, coding clinic determinations, CMS and other regulatory guidelines.
• Establish national and best-practice benchmarks and measure performance against benchmarks.
• Ensure accurate payment by using DRG grouper and claims processing platforms.
• Manage case volumes and audit schedules as assigned by Management.
• Support Lifetime Healthcare Companies' mission and values and maintain privacy standards.
• Regular attendance and reliability.
• Perform other functions as assigned by management.

Skills

ICD-10 coding

DRG/APR-DRG

Medical coding audits

Analytical skills

Regulatory compliance

Claims processing systems

Education

RHIA or RHIT or Nursing degree

Tools

DRG encoder

Claims processing systems

Job description

CDPHP in Albany, NY is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with deep ICD-10/DRG expertise to review acute inpatient records and validate DRG assignments. You will audit claims, ensure CMS guideline compliance, and mentor staff.

The role supports data quality and payment integrity, with remote work possible case-by-case. Qualified candidates typically hold RHIA/RHIT or nursing degrees and have 3+ years in DRG/ICD-10 auditing, plus strong analytical skills and