Job Description

The DRG Validation position requires an extensive background in inpatient DRG coding with a deep understanding of the MS-DRG and APR-DRG payment systems. The validator is responsible for auditing inpatient medical records, ensuring the accuracy of coding, provider documentation, and DRG assignment.

Key Responsibilities

Perform concurrent and retrospective clinically based and MS-DRG and APR DRG validation reviews in compliance with appropriate coding and payments adhering to Uniform

Hospital Discharge Date Set (UHDDS) and Medicare guidelines including Federal and State regulations.

Review the correct assignment of ICD-10-CM diagnosis & ICD-10-PCS procedure codes.

Effectively utilize facility Encoders, EMRs, abstracting systems (3M, EPIC, etc.) and auditing tools and systems (e.g., TruCode, 3M Standalone, etc.) proficiently to make audit determinations.

Write clear, accurate, and concise rationales supporting audit findings.

Compose physician queries for clarification of documentation.

Provide coder education referencing applicable coding references following audits.

Review DRG/coding denial letters and compose effectively supported appeal response letters to third party auditors and insurance carriers that summarize and support hospital position of upholding or overturning of External, PRO and/or RAC Determinations.

Provide written recommendations for optimal coding and DRG / SOI assignment.

Stay up to date on regulatory changes affecting coding rules and regulations.

Maintain proficiency on the Official Coding Guidelines for Coding and Reporting and AHA

Coding Clinics.

Meets or Exceeds Standards / Guidelines for productivity maintaining production goals set by the Director of HIM Technical Services.

Meets or Exceeds Standards / Guidelines for accuracy and quality achieving the expected level set by the Director of HIM Technical Services. Quality accuracy rate must be maintained at 95-100%.

Able to effectively communicate with physicians, CDI staff and other clinicians regarding documentation, queries and/or coding guidelines.

Qualifications

Must have one of the following AHIMA certifications: CCS, RHIT, or RHIA

Extensive knowledge of medical terminology, anatomy, coding terminology and coding guidelines for ICD-10-CM/PCS, CPT, Modifiers, etc.

Equivalent experience of 5+ years in DRG/Clinical Validation claims auditing, quality assurance or recovery auditing.

Minimum of 5+ years of working with ICD-10-CM/PCS, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, and payer reimbursement policies.

Adherence to Official Coding Guidelines for Coding and Reporting, Coding Clinic determinations, CMS, and other regulatory compliance guidelines and mandates which requires expert coding knowledge of DRG, ICD-10-CM and PCS codes.

Demonstrates basic skills in Microsoft Outlook, Word, Excel, PowerPoint, 3M, TruCode,Teams, SharePoint, and other applications.

Must have good written and verbal communication skills.

Possess the ability to educate health care professionals in various settings.

Responsible and self-sufficient with strong analytical and research skills.

Must be able to meet or exceed deadline completion times required.

Job Type: Full-time

Salary: From $80,000.00 per year

Benefits:

401(k)

401(k) matching

Dental insurance

Flexible schedule

Health insurance

Life insurance

Paid time off

Vision insurance

Schedule:8 hour shift

Work setting:Remote

Experience: ICD coding: 5 years (Required)

License/Certification:AHIMA Certification (Required)

About Jzanus Consulting

For over 25 years, Jzanus has been a premier provider of revenue integrity HIM services. Quality and trust, along with personal and professional integrity have been the cornerstones upon which we built our reputation and our success. Jzanus’s accomplishments are the result of our New York best practice experience, our proprietary technology platform and most importantly the Jzanus team. Our people are senior level professionals with extensive provider, payer, clinical, HIM and home care experience who are very aware of the business challenges that face you daily. Jzanus Consulting specializes in providing HIM coding validation, clinical documentation improvement, and cost outlier recovery to hospitals and hospital-owned physician organizations. We have earned the trust of our customers by utilizing only the most qualified HIM consultants. By ensuring compliance and coding accuracy for optimal reimbursements, we provide significant value to our customers.