Job Overview
Perform DRG validation reviews of medical records to ensure accuracy of ICD-10-CM/PCS code assignments and DRG determinations. Access proprietary systems to audit documentation, document findings, and apply clinical judgment for coding validation, including sequencing for inpatient claims.
Responsibilities
- Conduct audits of medical record documentation to verify principal and secondary diagnoses (including MCC and CC) and procedure codes.
- Adhere to official coding guidelines, coding clinics, and regulatory mandates.
- Utilize proprietary auditing systems to document determinations and rationale.
- Apply clinical review judgment for coding validation, including ICD-10-CM and ICD-10-PCS sequencing.
- Achieve productivity and quality performance standards.
- Assist with training new coders or auditors through monitoring, mentoring, feedback, and education.
- Maintain current knowledge of coding guidelines and complete required CEUs for RN license and coding certification.
- Attend training and meetings to enhance skills in clinical policies, procedures, rules, and regulations.
Qualifications
- Active, unrestricted RN licensure from the United States and in the state of primary home residency, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- At least one of the following coding certifications: RHIA, RHIT, CCS, CIC, CCDS, or CPC, maintained as a condition of employment.
- 3+ years clinical experience in an inpatient hospital setting.
- 2+ years of MS-DRG/APR-DRG coding or auditing experience with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies.
- Expert knowledge of ICD-10-CM coding, including principal diagnosis selection, CCs, MCCs, and conditions impacting severity of illness (SOI) and risk of mortality (ROM).
- Expert knowledge of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition per CMS requirements, Official Guidelines, and Coding Clinic guidance.
- Demonstrated ability to apply clinical review judgment for clinical determinations.
- Demonstrated proficiency in computer skills and typing, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and virtual meeting tools like Microsoft Teams and Zoom.
