APR-DRG Validator 

Job Specification

We’re seeking a DRG Validator NOT a coder. Reviews inpatient medical records to ensure ICD-10 coding and APR-DRG assignments are accurate, compliant, and appropriately reimbursed. This role focuses on APR-DRG inpatient coding disputes and audit reviews, collaborating with our senior coders to ensure accuracy, compliance, and high-quality outcomes. The Inpatient DRG Validator? is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company and its client. Also, the APR-DRG auditor is responsible for performing clinical reviews of medical records and other documentations to evaluate issues of coding and DRG assignment accuracy. Specializes in reviewing DRG coding in medical record sent in by acute care hospitals on submitted DRG. We are specifically looking for experienced auditors with strong ICD-10-CM/PCS knowledge and credentials such as RHIA, RHIT, CCS, CIC ONLY. 

Responsibilities:

• Abilities to analyze and audits claims by integrating medical chart coding principles, clinical guidelines and objectivity in the performance of medical audit activities.

• Exhibit advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions of audits claims.

• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters by providing recommendations to change, delete, or modify DRG’s.

• Maintains accuracy and quality standards as set by auditing concept, valid claim identification, and documentation purposes consistent with rationale in the letter generated.

• Ability to Identifies new claim by identifying potential claims where additional recoveries may be available, such as re-admissions DRG optimization and HACs.

• Manages priorities, collaborates with peers and ensures timely completion of inpatient coding reviews. Suggests and recommends high quality, high value concept and or process improvement and efficiency recommendations when possible. 

Required Qualifications:

• RHIA, RHIT, CCS and CIC certifications have held for at least one of these qualifications for a minimum of 3 years 

• APR-DRG coding and auditing experience

• 3 years plus experience performing inpatient coding reviews and audits in inpatient patient hospital settings 

• Ability to work independently and determine appropriate courses of action with less supervision.

• Excellent communication skills both written and verbal which is a crucial part of DRG audit

• General Knowledge of Microsoft office programs such as word, PowerPoint, access, and Excel 

Preferred Qualifications:

• Associate degree or higher in Health information Management (HIT) 

• Experience in APR-DRG coding and auditing 

• Experience with 3M encoder

• Experience with cost outlier and recovery is a plus.

Hours: Monday - Friday, 8am-5:30 (40 hours a week)

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Revenue Cycle division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, handling financial and other payment data, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.