RN DRG Coding Auditor

Conifer Revenue Cycle Solutions; Remote; USD 56,000 - 86,000; Full time

Job summary

A leading healthcare solutions provider is seeking a CRC Auditor to conduct coding and documentation quality reviews. This role involves generating appeal letters for denied claims and analyzing clinical documentation. The Auditor will collaborate with healthcare professionals and escalate trends to leadership. The ideal candidate will have a BSN or equivalent experience, RN license, and proficiency in clinical documentation integrity and inpatient coding guidelines. Strong communication skills and the ability to work independently are essential.

Benefits

Medical, dental, vision insurance

Paid time off

401(k) with employer match

Employee Assistance program

Qualifications

• Experience with clinical documentation integrity.
• Expertise in inpatient coding guidelines.
• Strong communication and interpersonal skills.

Responsibilities

• Conduct coding and documentation quality reviews.
• Create appeal letters based on clinical documentation.
• Collaborate with Physician Advisors on documentation issues.

Skills

Critical thinking

Analytical skills

Excellent communication

Detail-oriented

Moderate MS Office skills

Education

BSN Degree Program or equivalent experience

RN License

CCDS or inpatient coding certification

Tools

MS Excel

MS PowerPoint

Job description

Job Summary

The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims are coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and/or a formal appeal letter. The Auditor escalates trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor performs analysis on clinical documentation, evidence‑based criteria application outcome, physician documentation, physician advisor input, and completes review of the medical record related to clinical denials. The Auditor ensures appropriate action is taken within appeal time frames, communicates identified denial trends and patterns to CRC leadership, provides expert application of evidence‑based medical necessity review criteria, and works collaboratively to review, evaluate and improve the denial appeal process.

Essential Duties and Responsibilities

• Formulates and submits letters of appeal, creating an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence‑based medicine, community and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in the appropriate denial tracking tool (ACE) and maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per‑Diems, DRG’s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation‑specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

Knowledge, Skills, Abilities

• Effectively organizes work priorities.
• Demonstrates compliance with departmental safety and security policies and practices.
• Demonstrates critical thinking, analytical skills, and ability to resolve problems.
• Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision.
• Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals.
• Possesses excellent written and verbal communication skills.
• Detail oriented and able to work independently and in a team setting.
• Moderate skills in MS Excel and PowerPoint, MS Office.
• Ability to research difficult coding and documentation issues and follow through to resolution.
• Ability to work in a virtual setting under minimal supervision.
• Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes.

Vaccinations and Screenings

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID‑19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

Education / Experience

Education

• Minimum Required:
  • Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment.
  • RN License in the State of Practice.
  • Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
• Preferred/Desired:
  • Completion of BSN Degree Program.
  • CCDS certification or inpatient coding certification.

Experience

• Minimum Required:
  • Three to Five years Clinical RN Experience.
  • Three to Five years of Clinical Documentation Integrity experience.
  • Must have expertise with Interqual and/or MCG Disease Management Ideologies.
  • Strong communication (verbal/written) and interpersonal skills.
  • Knowledge of CMS regulations.
  • Knowledge of inpatient coding guidelines.
  • 1–2 years of current experience with reimbursement methodologies.
• Preferred/Desired:
  • Experience preparing appeals for clinical denials related to DRG assignment.
  • Strong understanding of rules and guidelines, including AHA's Coding Clinics, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD‑10, HCPCS.

Certificates, Licenses, Registrations

• Required:
  • RN.
  • CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA.
• Preferred: BSN.

Physical Demands

• Ability to lift 15–30 lbs.
• Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters, or other designated sites.
• Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews.

Work Environment

• Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

Other

• Interaction with facility HIM and/or physician advisors.
• Must meet the requirements of the Conifer Telecommuting Policy and Procedure.

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value‑based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

• Pay: $56,784.00 – $85,176.00 annually. Compensation depends on location, qualifications, and experience.
• Management level positions may be eligible for sign‑on and relocation bonuses.

Benefits

• Medical, dental, vision, disability, life, and business travel insurance.
• Paid time off (vacation & sick leave) – minimum of 12 days per year, accrued at a rate of approximately 1.84 hours per 40 hours worked.
• 401(k) with up to 6% employer match.
• 10 paid holidays per year.
• Health savings accounts, healthcare & dependent flexible spending accounts.
• Employee Assistance program, Employee discount program.
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act.

Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E‑Verify program. The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.