DRG Validation Auditor

Position Type: Full-Time

Office Location: Newtown Square, PA with remote opportunities available

Versalus Health is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. Versalus Health has expanded its product offering to include DRG Revenue Integrity services. By leveraging advanced analytics and DRG auditing and clinical expertise, Versalus Health provides programmatic solutions for DRG compliance and revenue integrity. Versalus offers outstanding growth opportunities, a competitive salary and benefits package including bonuses based on individual and company performance, and reimbursement for continuing education and association dues. Versalus has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Description:

The DRG Validation Auditor utilizes data analytics and proprietary algorithms to perform prebill or post bill DRG and Clinical Validation reviews to identify revenue integrity issues and opportunities. This position requires expert knowledge of MS-DRG and APR-DRG payment methodologies. The Auditor is responsible for validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, and the assignment of present on admission (POA) indicators and discharge disposition status for claims under review.

 Job Responsibilities:

  • Identifies both over and under payments. Reviews medical records and other hospital documents to validate that the clinical documentation supports the assigned ICD-10-CM/PCS codes, the selection of the principal diagnosis and discharge disposition following CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.
  • Effectively Utilizes Audit Tools. Utilizes 3M encoder and grouper software with advanced proficiency. Enters audit findings into our proprietary application accurately and in accordance with standard procedures.
  • Meets or exceeds standards for both quality and productivity set by the organization.
  • Other responsibilities as assigned. Duties may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing.

Education & Certification:

  • RN/RHIA/RHIT with CDIP or CCDS required. CCS is highly preferred and will be required after one year of employment. (Assistance is available for preparation.)
  • CDI/coding certifications, and/or professional license must be maintained as a condition of employment.

Work Experience:

  • A minimum 5 years of hospital or vendor inpatient coding and/or CDI experience required.
  • DRG appeal experience highly preferred.

Knowledge, Skills & Abilities

  • Expert Inpatient Coding Skills. Possess regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS-DRG and APR-DRG payment methodologies including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
  • Clinical Validation Skills. Ability to apply current industry standard clinical indicators, risk factors and treatment protocols used in clinical validation of payment impacting code assignment. Solid command of anatomy, physiology, pathology, laboratory, imaging, pharmacology, and disease assessment, management, and treatment.
  • Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes, and evaluates information gathered from, or generated by observation, experience, reflection, reasoning, or communication as a guide to validate audit results and correct as necessary.
  • Adaptability. Maintains effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures.
  • Initiative. Proactive and self-directed. Shows initiative and responsibility in taking the necessary steps towards problem resolution. Is self-sufficient and does not need to rely on others to complete a job.
  • Vivacity. Consistently maintains high levels of activity or productivity sustained over long working hours when necessary; operates with vigor, effectiveness, and determination.
  • Performance. Meets or exceeds both production and quality expectations while performing complex medical record audits. Able to execute under pressure of time constraints and while managing multiple responsibilities. Proactively prioritizes initiatives, effectively manages resources and can multi-task. Actively manages their work assignments and seeks additional tasks when appropriate. 
  • Communication Skills. Communicates clearly, proactively, and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise justifications in support of findings and successfully crafts appeal letters with precise logic.
  • Curious. Actively seek out new ideas, possibilities, and answers to the tough questions. Committed to life-long learning.
  • Detailed Oriented. Pays meticulous attention to detail, identifies aberrant code assignment, mines medical records for all relevant and supporting evidence, and conscientiously follows all steps in the audit.
  • PC Skills. Demonstrates proficiency in Microsoft Office, and Teams, Skype, WebEx, VPN access, navigating a variety of EHRs, and ability to problem solve Internet connectivity issues.

Physical Requirements:

May be expected to sit at a desk for long hours. Repetitive movement of hands and fingers – typing and/or writing. Occasional standing, walking, stooping, kneeling or crouching. Ability to reach with hands and arms, talk and hear.

Versalus Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law.

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