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

Excellus BCBS; Town of De Witt (NY); On-site; USD 65,346 - 142,322; Full time

Benefits offered by this job

Health and dental insurance

Retirement plan

Paid time off

Job summary

A healthcare insurance provider in New York seeks a Payment Integrity DRG Coding & Clinical Validation Analyst responsible for auditing inpatient claims and ensuring accurate documentation for coding. Candidates should have a strong background in ICD-10 coding, claims auditing, and possess relevant certifications. This role spans three levels, each requiring increasing experience and expertise in DRG payment systems and leadership capabilities.

Qualifications

• Three years of claims auditing experience in DRG coding for hospital settings.
• Experience with ICD-10CM and MS-DRG payment systems.
• Maintained coding certification (RHIA, RHIT, CCS, or CIC).

Responsibilities

• Analyze and audit acute inpatient claims based on coding principles.
• Perform complex audits with minimal direction.
• Provide expertise in developing audit data criteria.

Skills

ICD-10 coding

Analytical skills

Attention to detail

Leadership

Education

Associate or bachelor's degree in Health Information Management or Nursing

Tools

Claims processing systems

Auditing tools

Job description

Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)

Join to apply for the Payment Integrity DRG Coding & Clinical Validation Analyst role at Excellus BCBS.

Job Description

The Payment Integrity DRG Coding & Clinical Validation Analyst position requires extensive experience in acute facility-based clinical documentation and inpatient coding, with a strong understanding of MS‑DRG and APR‑DRG payment systems. Responsibilities include reviewing medical records for accurate provider documentation to support principal diagnoses, comorbidities, complications, secondary diagnoses, surgical procedures, and POA indicators. The analyst validates coding and DRG assignment accuracy, ensuring physician documentation aligns with hospital coded data and adheres to CMS and other regulatory standards.

Essential Accountabilities

Level I

• Analyzes and audits acute inpatient claims, integrating medical chart coding principles and clinical guidelines.
• Applies advanced ICD‑10 coding expertise and industry knowledge to substantiate conclusions.
• Adheres to official coding guidelines, coding clinic determinations, and CMS regulatory mandates.
• Establishes national and best‑practice benchmarks, measuring performance against them.
• Ensures accurate payment by independently using DRG grouper, encoder, and claims processing platform.
• Manages case volumes and review/audit schedules, prioritizing case loads per management assignment.
• Demonstrates integrity by supporting the Lifetime Healthcare Companies’ mission, values, and Corporate Code of Conduct.
• Maintains respect for member privacy per corporate privacy policies.
• Exhibits reliable attendance as required.
• Performs other functions as assigned by management.

Level II

• Performs complex audits or projects with minimal direction or oversight.
• Acts as an expert in medical coding and record review, overseeing complex assignments and challenging customers.
• Supports leadership in projects related to divisional/departmental strategies and initiatives.
• Participates and represents in audits, payment methodologies, and contractual agreements with cross‑functional teams or business partners.
• Serves as a mentor to new hires.
• Engages on department committees, both internal and external.

Level III

• Provides expertise in developing audit data criteria.
• Acts as a lead, offering training, guidance, complex performance analysis, and coaching to team members on continuous quality improvement.
• Resolves escalations in partnership with Payment Integrity staff.
• Provides backup support for management as necessary.

Minimum Qualifications

• Associate or bachelor’s degree in Health Information Management (RHIA or RHIT) or Nursing.
• Three (3) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and comprehensive knowledge of medical claims billing/payment systems and coding terminology.
• Maintained coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC) as a condition of employment.
• Intermediate analytical and problem‑solving skills with awareness of business analysis trends.
• Intermediate knowledge of PC, software, auditing tools, and claims processing systems.

Level II (Additional to Level I Qualifications)

• Five (5) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and advanced knowledge of medical claims billing/payment systems.
• Demonstrated ability across multiple skills, products, processes, and systems.
• Demonstrated leadership of initiatives with occasional guidance from management.
• Advanced analytical, problem‑solving, and judgment skills.
• Advanced knowledge of PC, software, auditing tools, and claims processing systems.

Level III (Additional to Level II Qualifications)

• Eight (8) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and expert knowledge of medical claims billing/payment systems.
• Demonstrated leadership skills.
• Expertise as a subject‑matter expert or consultant to other departments.
• Ability to work independently and lead key business initiatives.
• Expert proficiency in auditing skillset and managing complex assignments.
• 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.

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 – $65,346 – $117,622

Level II: Grade E5 – $71,880 – $129,384

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

The salary range indicated is the minimum and maximum of the salary range for each level. Actual salary will vary based on factors such as budget, experience, education, and internal equity. The posted salary range reflects one component of our total rewards package, which may include health and dental insurance, retirement plan, wellness program, paid time off, and holidays.