DRG Validation Coding Auditor

Thank you for considering a career at Ensemble Health Partners!

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.

Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!

O.N.E Purpose:

Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity:

CAREER OPPORTUNITY OFFERING:

Bonus Incentives

Paid Certifications

Tuition Reimbursement

Comprehensive Benefits

Career Advancement

This position pays between $69,400 to $119,700 annually based on experience

The Inpatient/DRG Validation Coding Auditor performs documentation and coding audits for all acute inpatient services for clients. Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns. Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations.

Has an extensive understanding of reimbursement guidelines, specifically related to DRG (MS, APR, Tricare, etc.) payment systems.

Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. Ensures that the assigned DRG reflects the severity of the patient’s condition, and the resources used during their hospital stay.

Assesses whether the clinical documentation supports the coded diagnoses and procedures. Verifies that the medical record adequately justifies the assigned DRG.

Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities.

Maintains productivity and quality goals as set by audit leaders.

Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics.

Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations.

Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines.

Completes required education through internal application, compliance training and other mandatory educational requirements.

Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately.

Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided.

Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions. Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies.

Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns. Shares and assists in development of concepts and or process improvement, tools, etc.