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DRG Validation Specialist
Maine Health

Location: Home-based`, Remote
Work Setting: Hospital
Job Function:
Coding – Auditor
Job Type:


Under the general direction of the Coding Director, this position is responsible for performing DRG Validation quality reviews for inpatient coded records to validate ICD 10 CM and PCS codes for appropriate DRG assignment. This position reviews coded claims to identify any missed secondary diagnosis and/or procedures, ensuring compliance with all DRG mandates and reporting requirements. Report results, findings and recommendations to the Coding Director and assists with the development of process improvements to maintain data quality.

Job Description

Performs data and quality reviews on inpatient records to validate the ICD 9 CM Codes, DRG Assignment, missed secondary diagnosis and procedures.
● Ensures compliance with all DRG mandates and reporting requirements.
● Monitors Medicare and other DRG payer bulletins and manuals for any updates.
● Creates and monitors inpatient case mix reports and the top 25 DRG’s in the facility to identify patterns, trends, and variations in the facilities frequently assigned DRG groups. Monitors the CMS PEPPER report to identify trends.
● Reviews and evaluates Coder queries to ensure compliance with AHIMA’s coding query guidelines.
● Assist inpatient coders with complex coding questions.
● Continuously evaluates the quality of the clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG group and payment.
● Provides and assists the Director of Coding with arranging for training of facility healthcare professionals in the use of coding guidelines and practices, proper documentation techniques, medical terminology, disease processes, appropriate to the job description and function as it relates to the DRG and other clinical quality management factors.
● Review and responds to any internal or external DRG validation audits. i.e. RAC’s, 3rd party insurance carriers, and/or compliance.
● Provides quality reviews/ DRG validation reviews for inpatient coding work. Providing feedback to the supervisor for appropriate follow up.
● Abides by the STANDARDS OF ETHICAL CODING as set forth by the American Health Information Management Association (AHIMA) and adhere to official coding guidelines. .

Required Qualifications

1. Education: Associates Degree in Health Information Management and/or Bachelors’ Degree in Health Information Management, or other science-based degree such as nursing, required.
2. License/Certifications: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) required.
3. Experience: Minimum of three (3) years’ experience as an inpatient coder at a large (300 plus bed) acute care or academic teaching facility required.
4. Advanced coding skills and knowledge of revenue cycle, billing systems, EPIC Electronic Health Record and 3M Encoder, ICD 10 training, Computer Assisted Coding software (CAC); effective communication to serve as a knowledge resource and mentor on coding and compliance issues. Demonstrates ability to work effectively and collaboratively with Clinical Documentation Improvement Specialists (CDIS) and other healthcare professionals.

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Posted: October 31, 2022 at 1:55 PM
Post ID: 72526

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