Payer Audit Lead

Commitment: 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. Versalus Health provides programmatic solutions for DRG compliance and revenue integrity by leveraging advanced analytics and DRG auditing and clinical expertise. 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 Payor Audit Lead manages the daily workflow activities of inpatient DRG payer denials on behalf of our hospital client partners. Responsibilities include reviewing denial letters, assignment of case reviews, management of turnaround times, data entry of audit recommendations, and responsibility for professional and effective appeal responses. In addition, the lead is responsible for identifying compliance risk, analyzing denial trends, performing root cause analysis, determining effective remedies, and communicating results to key stakeholders to improve regulatory compliance and foster a reduction in denial risk.

Job Responsibility:

  • Performs comprehensive reviews of inpatient medical records to validate the MS/APR DRGs assigned for Medicare, Commercial, and Third-Party paid claims.
  • Validates that all ICD-10-CM/PCS, discharge disposition codes, and Hospital Acquired Condition (HAC), Present on Admission (POA) indicators impacting payment are documented, clinically supported, and assigned following Official Coding Guidelines, compliant query practices and current clinical validation criteria.
  • Utilizes audit reference tools and applications (e.g., proprietary denials management application, TruCode, and 3M encoder and grouper software and references).
  • Reviews denial letters rationale and formulates custom appeal response letters utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence-based medicine, and official coding guidelines.
  • Accurately abstracts denial audit findings into our proprietary application in accordance with standard procedures.
  • Prepares management and client outcome reports.
  • Maintains subject matter expertise in clinical validation criteria and practices, ICD-10-CM/PCS code sets, coding guidelines, clinical documentation integrity, and inpatient payment methodologies.
  • Trains and advises auditors on effective appeal strategies and manages the quality of appeal responses.
  • Manages the appeal’s workflow to ensure on-time delivery of denial responses.
  • Investigates and problem solves denial issues in collaboration with DRG Appeals Support team.
  • Identifies DRG audit & denial trends by payer & advises clients of strategies to bulletproof documentation and improve final coding to limit future recoveries.
  • Attends continuing education workshops, webinars, etc., for coding and documentation integrity and compliance.
  • Perform other duties as assigned.

Required Education/Experience:

  • RHIA/RHIT with CCS required. CDIP or CCDS is highly preferred and may be required after one year of employment. (Assistance is available for preparation.)
  • Certifications and/or professional license must be maintained as a condition of employment.
  • A minimum of 5 years of experience in any of the following roles:
    • Inpatient coding quality assurance
    • DRG validation
    • DRG appeal
    • Clinical Documentation Integrity (CDI) as a Clinical Documentation Specialist (CDS), Educator, or Manager

Knowledge, Skills, and Abilities:

  • Extensive Inpatient Coding Skills. Possess regulatory ICD-10-CM/PCS coding expertise coupled with subject matter expertise in MS/APR DRG payment methodologies, including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
  • Clinical Validation Skills. Demonstrate the ability to identify, apply, and validate the use of 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, disease assessment, management and treatment is required.
  • 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. Is 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.
  • Planning and Organization. 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 and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Committed to life-long learning. Pays meticulous attention to detail, identifies aberrant code assignment, mines medical records for all relevant and supporting evidence, intuitively understands appeal strategies and conscientiously follows all steps in the audit and appeals process.
  • PC Skills. Demonstrates proficiency in Microsoft Office and Teams, Skype, WebEx, VPN access, navigating various EHRs, and ability to problem solve Internet connectivity issues.

Benefits:

  • Enjoy work-life balance with a predictable schedule
  • Compensation includes salary plus bonus opportunities
  • Medical, Dental, Vision coverage, 401K
  • Holidays, paid time off, short term and long-term disability insurance, and life insurance
  • Reimbursement for continuing education and association dues

Physical Requirements:

May be expected to sit at a desk for long hours. Must have a private and secure space to work, including a secure Internet connection. 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. Exert up to 20 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

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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