Job Requirements

The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for clients. Please share relevant profiles at the earliest. Let us know if you need any further details.

We are looking for professionals with strong expertise in DRG. The ideal candidates should have:

Key Responsibilities

Perform comprehensive inpatient DRG validation reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.
Based on the evidence presented in the medical records, determine, and record the appropriate (revised) Diagnosis Codes, Procedure Codes and Discharge Status Code applicable to the claim.
Using the revised codes, regroup the claim using provided software to determine the new DRG
Where the regrouped new DRG differs from what was originally claimed by the provider, write a customer facing rationale or findings statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review
Document all aspect of audits including uploading all provider communications, clinical rationale, and/or financial research
Identify new DRG coding concepts to expand the DRG product.
Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
Meet and/or exceed all internal and department productivity and quality standards
Recommend new methods to improve departmental procedures
Achieve and maintain personal production and savings quota
Maintain awareness of and ensure adherence to Zelis standards regarding privacy

Skills, Knowledge, And Experience

Registered Nurse licensure preferred
Graduate
Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)
3 – 5 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
Understanding of hospital coding and billing rules
Clinical skills to evaluate appropriate Medical Record Coding
Experience conducting root cause analysis and identifying solutions
Strong organization skills with attention to detail
Outstanding verbal and written communication skills

Note: These resources should possess certification either in CIC or CCS (Mandatory)

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