For HR Use Only

Required Skills

Required Experience

ESSENTIAL FUNCTIONS
(Responsibilities/Accountabilities)

Reviews coded diagnosis and procedures, comparing to medical record to confirm that the original DRG reimbursement is correct and appropriate as follows:
- Verifies that primary diagnosis is the reason for admission.
- Verifies that all complicating conditions are appropriate and documented in medical records.
- Verifies that the sequencing of the diagnostic codes are appropriately assigned.
- Verifies that DRG grouping is appropriate based on documented diagnosis and procedures.
- Verifies accuracy of original claim allowance utilizing client base rates, relative weights, and other reimbursement exceptions.

Clearly communicate in writing clinical rationale and/or coding rules to substantiate recommended coding & DRG change.
Reevaluate audit findings and formulate responses based on appeals received by providers.
Maintains open communication with team, management, and providers.
-All other duties as assigned.

REQUIREMENTS
(Knowledge, Skills, Abilities)

Required Experience:
-Diploma in nursing required (Associate or Bachelors degree in nursing preferred)
-Active unrestricted nursing license in state of employment
-3 years of clinical nursing experience
-DRG validation audit or coding experience required

-Must be able to complete and pass a pre hire assessment for DRG coding concepts
-Skilled in Word, Excel and Outlook
-Basic math skills
-Must be able to work independently in a remote environment with minimal supervision
-Strong verbal and written communication skills

Preferred Experience:
-Coding Certification (must be willing to obtain coding certification within 1 year of employment)
-Healthcare claim audit knowledge in the following areas a strong plus: One Day Admissions, Readmissions, ER Visits, Utilization Management/Medical Necessity, Outlier Payments
-Knowledge of outpatient billing
-Working knowledge of InterQual criteria a plus

- Working knowledge of encoding software such as 3M or TruCode a plus

Position requires the candidate to be detail oriented and able to manage with tight deadlines. Must have the ability to prioritize and organize tasks and shift priorities as needed.

This position also requires minimal travel as needed. Training is 100% remote.