Senior Specialist, DRGV

About the job

Position Name: Senior Specialist, DRGV

Experience: 4- 8 years

About Us

Ensemble Health Partners is the single solution for a frictionless revenue cycle. Founded in 2014, we set out to redefine what is possible in healthcare by empowering people to be the difference.

Today, Ensemble supports revenue cycle excellence for hundreds of hospitals across the United States. From talent to technology, we provide a comprehensive healthcare revenue cycle management solution that enables industry leaders to achieve sustained performance and measurable outcomes.

Ensemble Health Partners India, the company's Global Capability Center with its flagship facility in Hyderabad, serves as a hub for certified professionals supporting critical revenue cycle functions across the organization.

Essential Job Functions

Customer Obsession - Consistently provide exceptional experience for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

Embracing New Ideas - Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

Striving for Excellence - Execute at a high level by demonstrating our Best in KLAS Ensemble

Difference Principles and consistently delivering outstanding results.

Onboarding and Training: Guiding new hires through department-specific processes, policies, and systems, including IT setup and access requests

Mentorship: Supporting internal transfers and current team members through peer-to-peer education, regional or team-based sessions, and individualized coaching

Documentation: Creating and maintaining SOPs, job aids, onboarding binders, and training materials tailored to departmental or client-specific needs

Quality Audits: Conducting performance audits to ensure adherence to best practices, though not always responsible for delivering audit feedback

Special Projects: Participating in initiatives like SWAT teams, documentation updates, and system super-user roles

Job Responsibilities

• 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.