Nurse Coder DRG Auditor I

Utilize coding guidelines and clinical guidelines to perform DRG or APC validation

Validate principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses and procedures utilizing the medical record

Evaluate short stay claims for medical necessity of an inpatient level of care

Apply CPT and ICD-10 guidelines

Apply policies, procedures, guidelines and regulations developed by Centers for Medicare and Medicaid Services (CMS), commercial payers, InterQual, MCG, and Trend Health Partners

Provide appeal responses for claims of the above types utilizing industry standards and company/client policies

Assist with new concept development

Assist with claim selection criteria

Assist with itemized bill review as needed

Maintain licensures, certifications and continuing education requirements

May require client communication to support findings

Appeals experience a plus

APR-DRG experience a plus

Client communication experience a plus

Concept development experience a plus

Claim selection experience a plus

Experience with machine learning/artificial intelligence a plus

Case Management and/or Utilization Review experience a plus

Clinical Documentation Improvement experience a plus

Itemized bill validation experience a plus

Quality Assurance experience a plus

Management experience a plus

Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) a plus

TruCode/TruBridge, 3M, WebStrat or similar experience a plus

This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.

The nature of the work is sedentary, and the employee will be sitting most of the time.

Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.

Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.

Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.

Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.