DRG validation


A Growing Diversified Revenue Cycle Healthcare company located in Franklin Square, NY is looking for full-time hybrid and per diem experienced DRG (Diagnosis Related Groups) Validation professional.

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.

Position qualifications

  • 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

Qualificiations for the DRG validation

  • 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
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