DRG Coding Auditor - CDI Remote - $10K Sign On Bonus

JOB SUMMARY The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations, and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and/or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership, and Conifer Compliance as warranted. The Auditor will perform analysis on clinical documentation, evidenced-based criteria application outcome, physician documentation, physician advisor input, and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence-based medical necessity review criteria tool. Works collaboratively to review, evaluate, and improve the denial appeal process. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned.

• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community, and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG’s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding, and reimbursement methodologies and utilization management specialty areas.

KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Effectively organizes work priorities
• Demonstrates compliance with departmental safety and security policies and practices
• Demonstrates critical thinking, analytical skills, and ability to resolve problems
• Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
• Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
• Possesses excellent written and verbal communication skills
• Detail-oriented and ability to work independently and in a team setting
• Moderate skills in MS Excel and PowerPoint, MS Office
• Ability to research difficult coding and documentation issues and follow through to resolution
• Ability to work in a virtual setting under minimal supervision
• Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes

EDUCATION / EXPERIENCE Includes minimum education, technical training, and/or experience required to perform the job.

• Minimum Required:
• Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment
• RN License in the State of Practice
• Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Preferred/Desired:
• Completion of BSN Degree Program
• CCDS certification or inpatient coding certification

CERTIFICATES, LICENSES, REGISTRATIONS

• Required:
• RN,
• CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC, or CPMA
• Preferred: BSN

COMPENSATION AND BENEFIT INFORMATION

• Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience.
• Conifer offers the following benefits, subject to employment status:
• Medical, dental, vision, disability, life, and business travel insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.

#J-18808-Ljbffr Salary: USD 56784 - 85176 per year Experience: 3 years required