Payment Integrity DRG Coding & Clinical Validation ...

Job Description: Summary: The Payment Integrity DRG Coding & Clinical Validation Analyst position has an extensive background in acute facility-based clinical documentation, and/or inpatient coding and has a high level of understanding of the current MS-DRG, and APR-DRG payment systems. This position is responsible for reviewing medical records for appropriate provider documentation to support the principal diagnosis, co-morbidities, complications, secondary diagnosis, surgical procedures, POA indicators to validate coding and DRG assignment accuracy, insuring the physician documentation supports the hospital coded data. Essential Accountabilities: Level I u00b7 Analyzes and audits acute inpatient claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Draws on advanced ICD-10 coding expertise. Clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently. u00b7 Adheres to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge u2013 DRG &ICD 10. u00b7 Establishes national and best practice benchmarks and measures performance against benchmarks. u00b7 Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform. u00b7 Manages case volumes and review/audit schedules, prioritizing case load as assigned by Management. u00b7 Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companiesu2019 mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. u00b7 Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. u00b7 Regular and reliable attendance is expected and required. u00b7 Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) u00b7 Performs complex audits or projects with minimal direction or oversight. u00b7 Acts as an expert in reviewing medical coding and medical record review with ability to oversee complex assignments, challenging customers, and highly visible issues. u00b7 Supports leadership in projects related to divisional/departmental strategies and initiatives. u00b7 Participates and represents in audits, payment methodologies, contractual agreements, with cross functional teams or with business partners as needed. u00b7 Serves as a mentor to new hires. u00b7 Demonstrates ability to participate and represent department on interna/external committees. Level III (in addition to Level II Accountabilities) u00b7 Provides expertise in developing data criteria for audits. u00b7 Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members around methods of continuous quality improvement. u00b7 Serves as an expert and resource for escalations and works directly with Payment Integrity staff to resolve issues and escalation problems. u00b7 Provides backup support for Management as necessary. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels u00b7 Associate or bacheloru2019s degree in health information management (RHIA or RHIT) or a Nursing Degree. u00b7 Three (3) yearsu2019 experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting. u00b7 Three (3) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology. u00b7 Coding Certification is to be maintained as a condition of employment of one of the following: RHIA or RHIT, Inpatient Coding Credential u2013 CCS or CIC. u00b7 Intermediate analytical and problem-solving skills; as well as keeps abreast of latest trends related to business analysis. u00b7 Intermediate knowledge of PC, software, auditing tools and claims processing systems. Level II (in addition to Level I Qualifications) u00b7 Five (5) yearsu2019 experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting. u00b7 Five (5) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology. u00b7 Demonstrated ability across multiple skills, products, processes, and systems with the Division. u00b7 Demonstrated ability to lead initiatives with occasional guidance and assistance from management and/or others. u00b7 Advanced analytical, problem solving, and judgement skills. u00b7 Advanced knowledge of PC, software, auditing tools and claims processing systems. Level III (in addition to Level II Qualifications) u00b7 Eight (8) yearsu2019 experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting. u00b7 Eight (8) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology. u00b7 Demonstrated leadership skills. u00b7 Demonstrated ability as a subject matter expert or consultant to other departments. u00b7 Demonstrated ability to work independently and assumes lead role in key business initiatives. u00b7 Expert proficiency in analytical skills, auditing skillset and ability to manage complex assignments, challenging situations, and highly visible issues. u00b7 Demonstrated expert proficiency in project management and presentation skills. Physical Requirements: u00b7 Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer. u00b7 Ability to travel across the Health Plan service region for meetings and/or trainings as needed. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation Range(s): Level I: Grade E4: Minimum: $65,346- Maximum: $117,622 Level II: Grade E5: Minimum: $71,880 - Maximum: $129,384 Level III: Grade E6: Minimum: $79,068 - Maximum: $142,322 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the positionu2019s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Created: 2025-10-23