DRG Clinical Validation Auditor
20 hours ago
Position Title:
DRG Clinical Validation Auditor - IloiloShift:
Job Description:
"Responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.
• Primary duties may include but are not limited to:
• Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
• Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
• Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters.
• Maintains accuracy and quality standards as established by audit management.
• Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
• Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.
• Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
Required Qualifications:
US RN - with at least two years of hospital experience
Several years of inpatient hospital coding experience
One or more of the following certification:
• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)
• Certified Professional Coder (CPC)
• Inpatient Coding Credential such as CCS or CIC
No specific state licensure
Preferred Qualifications (at least 1- Bed side nursing)
• ICU, CCU, Emergency Room, Trauma Care
• -RHIT or RHIA (preferred Certification)"
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