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

Univera Healthcare; Buffalo (NY); On-site; USD 65,346 - 117,622; Full time

Benefits offered by this job

Group health and/or dental insurance

Retirement plan

Paid time away from work

Paid holidays

Wellness program

Job summary

Univera Healthcare in Buffalo, New York is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst. This role requires expertise in acute facility-based clinical documentation and an understanding of MS-DRG and APR-DRG payment systems. You will review medical records for documentation accuracy, ensuring compliance with coding standards.

This position offers a competitive salary range of $65,346 to $117,622, depending on experience and qualifications. Remote work may be possible based on individual circumstances.

Qualifications

• Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
• Intermediate knowledge of PC, software, auditing tools and claims processing systems.
• Coding Certification such as RHIA or RHIT, CCS or CIC is required.

Responsibilities

• Analyzes and audits acute inpatient claims.
• Ensures compliance with coding guidelines and CMS mandates.
• Provides training and guidance to team members.

Skills

Analytical skills

Problem-solving skills

ICD-10 coding expertise

Attention to detail

Education

Associate or bachelor’s degree in health information management (RHIA or RHIT) or Nursing Degree

Tools

DRG grouper

Claims processing systems

Auditing tools

Job description

Job Description

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

Essential Accountabilities

Level I

• Analyzes and audits acute inpatient claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Draws on advanced ICD‑10 coding expertise and industry knowledge to substantiate conclusions. Performs work independently.
• Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge – 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 leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• 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 ability to oversee complex assignments, challenging customers, and 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 with business partners as needed.
• Serves as a mentor to new hires.
• Demonstrates ability to participate and represent 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

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 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.

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 setting.
• Five (5) 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.
• Demonstrated ability across multiple skills, products, processes, and systems with the Division.
• Demonstrated ability to lead initiatives with occasional guidance and assistance from management and/or others.
• Advanced analytical, problem solving, and judgement 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 setting.
• Eight (8) 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.
• Demonstrated leadership skills.
• Demonstrated ability as a subject matter expert or consultant to other departments.
• Demonstrated ability to work independently and assumes 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.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

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.

Compensation Range(s)

Level I: Grade E4 – Minimum: $65,346, Maximum: $117,622
Level II: Grade E5 – Minimum: $71,880, Maximum: $129,384
Level III: Grade E6 – Minimum: $79,068, Maximum: $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 factors including, but not limited to, 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 of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case‑by‑case basis.