DRG Validation Coding Auditor

March 12

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Ensemble Health Partners

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Ensemble Health Partners is a leading provider of revenue cycle management (RCM) services for healthcare organizations. They offer an end-to-end RCM solution that helps hospitals, health systems, and affiliated physician groups optimize their revenue cycles, reduce denials and underpayments, and enhance patient experiences using a combination of expert management and advanced technology. Ensemble Health Partners leverages certified operators and AI to deliver consistent results, improve collections, and support future growth for healthcare providers. They are recognized for their robust client partnerships and commitment to delivering reliable revenue lift and cost savings for their clients.

Revenue cycle consulting • Revenue cycle assessments • Revenue recovery • Revenue Cycle • EPIC

10,000+ employees

⚕️ Healthcare Insurance

☁️ SaaS

🏢 Enterprise

💰 Private Equity Round on 2022-03

📋 Description

• The Inpatient/DRG Validation Coding Auditor performs documentation and coding audits for all acute inpatient services for clients. • Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. • Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns. • Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations. • Has an extensive understanding of reimbursement guidelines, specifically related to DRG (MS, APR, Tricare, etc.) payment systems. • Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. • Ensures that the assigned DRG reflects the severity of the patient’s condition, and the resources used during their hospital stay. • Assesses whether the clinical documentation supports the coded diagnoses and procedures. • Verifies that the medical record adequately justifies the assigned DRG. • Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. • Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities. • Maintains productivity and quality goals as set by audit leaders. • Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics. • Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations. • Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines. • Completes required education through internal application, compliance training and other mandatory educational requirements. • Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately. • Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided. • Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions. • Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies. • Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns. • Shares and assists in development of concepts and or process improvement, tools, etc.

🎯 Requirements

• 5+ years of coding experience. • 3+ years of facility coding audit experience (such as DRG and APC Validation). • Proficiency in multiple EMR’s, encoders, and the Microsoft Office suite. • Educated in HIPAA regulations; must maintain strict confidentiality of patient and client information. • Consistently achieves quality and productivity standards. • Ability to organize and complete work in a timely manner. • Ability to read, write and effectively communicate in English. • Ability to understand medical/surgical terminology. • Above average written and verbal communication skills.

🏖️ Benefits

• Bonus Incentives • Paid Certifications • Tuition Reimbursement • Comprehensive Benefits • Career Advancement