Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Ce[...]

Lifetime Benefit Solutions, Inc.; Buffalo (NY); On-site; USD 65,346 - 117,622; Full time

Benefits offered by this job

Group health insurance

Retirement plan

Paid time off

Job summary

Lifetime Benefit Solutions, Inc. is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst for detailed review of medical records and validation of coding accuracy. Responsibilities include ensuring compliance with coding guidelines and providing training to new hires.

The ideal candidate should have a strong background in ICD-10 coding and experience in claims auditing. Remote work may be available depending on the role.

Qualifications

• Three years’ experience in claims auditing, quality assurance, or recovery auditing.
• Understands MS/APR DRG coding and medical necessity criteria.
• Intermediate knowledge of PC software and auditing tools.

Responsibilities

• Review medical records for coding and DRG assignment accuracy.
• Analyze inpatient claims and ensure compliance with coding guidelines.
• Provide training and guidance to team members.

Skills

ICD-10 coding expertise

Analytical skills

Problem-solving skills

Knowledge of medical claims processing

Education

Associate or bachelor’s degree in health information management or nursing

Certification like RHIA, RHIT, CCS, or CIC

Tools

Claims processing systems

Auditing tools

Job description

Job Description

The Payment Integrity DRG Coding & Clinical Validation Analyst has extensive background in acute facility-based clinical documentation and/or inpatient coding, with a high level of understanding of current MS‑DRG and APR‑DRG payment systems. This position reviews medical records to support principal diagnosis, co‑morbidities, complications, secondary diagnoses, surgical procedures, and POA indicators, validating coding and DRG assignment accuracy and ensuring physician documentation supports the hospital coded data.

Summary

Responsible for reviewing medical records to validate coding and DRG assignment accuracy, ensuring that physician documentation supports hospital coded data.

Essential Accountabilities

Level I

• Analyzes and audits acute inpatient claims, integrating medical chart coding principles, clinical guidelines, and objective audit activities. Draws on advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions and performs work independently.
• Adheres to official coding guidelines, coding clinic determinations, CMS and other regulatory compliance guidelines and mandates, requiring expert coding knowledge of DRG & ICD‑10.
• Establishes national and best‑practice benchmarks and measures performance against benchmarks.
• Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
• Manages case volumes and review/audit schedules, prioritizing case load as assigned by Management.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and living the Lifetime Way values and beliefs.
• Maintains a high regard for member privacy in accordance with corporate privacy policies and procedures.
• Provides regular and reliable attendance.
• Performs other functions as assigned by Management.

Level II (in addition to Level I accountabilities)

• Performs complex audits or projects with minimal direction or oversight.
• Acts as an expert in reviewing medical coding and medical record review with the ability to oversee complex assignments, challenge customers, and handle highly visible issues.
• Supports leadership in projects related to divisional/departmental strategies and initiatives.
• Participates and represents in audits, payment methodologies, contractual agreements, with cross‑functional teams or business partners as needed.
• Serves as a mentor to new hires.
• Demonstrates ability to participate and represent the department on internal/external committees.

Level III (in addition to Level II accountabilities)

• Provides expertise in developing data criteria for audits.
• Acts as a lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members around methods of continuous quality improvement.
• Serves as an expert and resource for escalations and works directly with Payment Integrity staff to resolve issues and escalation problems.
• Provides backup support for Management as necessary.

Minimum Qualifications

NOTE: Multiple levels of classification are differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. The following qualifications apply to all levels unless otherwise specified.

All Levels

• 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 settings.
• Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, with broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology.
• Coding certification maintained as a condition of employment, such as RHIA or RHIT, Inpatient Coding Credential—CCS or CIC.
• Intermediate analytical and problem‑solving skills and awareness of current business analysis trends.
• Intermediate knowledge of PC software, auditing tools, and claims processing systems.

Level II (in addition to Level I qualifications)

• Five (5) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or other acute facility settings.
• Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, with broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology.
• Demonstrated ability across multiple skills, products, processes, and systems with the division.
• Demonstrated ability to lead initiatives with occasional guidance and assistance from management or others.
• Advanced analytical, problem‑solving, and judgment skills.
• Advanced knowledge of PC software, auditing tools, and claims processing systems.

Level III (in addition to Level II qualifications)

• Eight (8) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or other acute facility settings.
• Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, with broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology.
• Demonstrated leadership skills.
• Demonstrated ability as a subject‑matter expert or consultant to other departments.
• Demonstrated ability to work independently and assume a lead role in key business initiatives.
• Expert proficiency in analytical skills, auditing skillset, and ability to manage complex assignments, challenging situations, and highly visible issues.
• Demonstrated expert proficiency in project management and presentation skills.

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
• Ability to travel across the health‑plan service region for meetings and/or trainings as needed.

Compensation Range(s)

Level I: Grade E4—$65,346 – $117,622

Level II: Grade E5—$71,880 – $129,384

Level III: Grade E6—$79,068 – $142,322

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on budget available, prior experience, knowledge, skill, and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package; other components may include group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Remote work may be available for all jobs posted by the LBS Recruitment team; decisions are made on a case‑by‑case basis.

Equal Opportunity Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.