Remote DRG Coding & Clinical Validation Analyst

Excellus BlueCross BlueShield; City of Utica (NY); On-site; USD 65,000 - 118,000; Full time

Benefits offered by this job

Remote work option

Job summary

Excellus BlueCross BlueShield is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to review inpatient records for accurate DRG assignments and coding. The role emphasizes MS-DRG and APR-DRG knowledge, provider documentation, and adherence to CMS guidelines.

You will audit claims, support complex projects, and mentor more junior staff. Candidates should have 3+ years of MS-DRG/APR-DRG experience, RHIA/RHIT or nursing degree, and strong analytical skills.

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.

Responsibilities

• Analyzes and audits acute inpatient claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
• Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
• 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.

Skills

ICD-10 coding

MS-DRG knowledge

APR-DRG knowledge

Claims auditing

Education

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

Job description

Excellus BlueCross BlueShield is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst to review inpatient records for accurate DRG assignments and coding. The role emphasizes MS-DRG and APR-DRG knowledge, provider documentation, and adherence to CMS guidelines.

You will audit claims, support complex projects, and mentor more junior staff. Candidates should have 3+ years of MS-DRG/APR-DRG experience, RHIA/RHIT or nursing degree, and strong analytical skills.