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

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

Job summary

CDPHP is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to review inpatient records and validate DRG assignments, ensuring the physician documentation supports principal diagnosis, co-morbidities, procedures, and POA indicators.

This role progresses from Level I to Level III responsibilities, conducts complex audits, mentors staff, and partners with cross-functional teams to improve payment accuracy and regulatory compliance across the health plan.

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 ensure coding accuracy.
• Adhere to official coding guidelines, coding clinic determinations, and CMS and other regulatory guidelines.
• Establish national and best practice benchmarks and measure performance against benchmarks.
• Ensure accurate payment by using DRG grouper, encoder, and claims processing platform.
• Manage case volumes and audit schedules as assigned by Management.
• Mentor new hires and participate in cross-functional audits and initiatives.
• Provide leadership in data criteria development for audits and act as a subject matter expert.

Skills

ICD-10 coding

DRG coding

Auditing

Analytical skills

Problem-solving

Education

RHIA/RHIT or Nursing Degree

Tools

DRG encoder

Claims processing systems

Auditing tools

Job description

Job Description:

Summary

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, POA indicators to validate coding and DRG assignment accuracy, insuring 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. Clinical guidelines, 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 interna/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: We include multiple levels of classification 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. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

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

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: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis.

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.