Remote DRG Coding & Clinical Validation Analyst

Capital District Physicians Health Plan Inc; Town of De Witt (NY); Hybrid; USD 65,000 - 142,000; Full time

Job summary

CDPHP in Albany, NY is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with deep experience in acute facility-based documentation and inpatient coding to validate DRG assignments and ensure hospital data accuracy.

The role conducts audits, adheres to coding guidelines, mentors staff, and partners with cross-functional teams on payment methodologies, with opportunities for remote work on a case-by-case basis.

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

• Analyzes and audits acute inpatient claims using ICD-10 coding principles and DRG accuracy.
• Adheres to official coding guidelines and CMS requirements.
• Establishes benchmarks and measures performance against them.
• Ensures accurate payment by using DRG grouper, encoder, and claims platform.
• Leads and mentors new hires.
• Provides training and coaching within the team.

Skills

ICD-10 coding

DRG coding

Quality assurance

Auditing

Regulatory compliance

PC software

Education

RHIA or RHIT

Nursing Degree

Tools

DRG encoder

Claims processing systems

Auditing tools

MS-DRG/APR-DRG knowledge

Job description

CDPHP in Albany, NY is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with deep experience in acute facility-based documentation and inpatient coding to validate DRG assignments and ensure hospital data accuracy.

The role conducts audits, adheres to coding guidelines, mentors staff, and partners with cross-functional teams on payment methodologies, with opportunities for remote work on a case-by-case basis.