DRG Validation Auditor

This is a remote role

We are seeking a DRG validation auditor specializing in coding-related denials, reimbursement audits, and clinical documentation improvement. This Auditor will be part of a team of clinicians, engineers, product managers, and other domain experts who are applying state-of-the-art machine learning software to improve the data quality and medical coding practices of providers. This is an opportunity to help inform the next generation in auditing software as well as to work in a dynamic environment with a high-performing team. The ideal candidate for this position needs to have both an inpatient and outpatient coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient MS-DRG/APR-DRG, and Outpatient CPT-4/HCPCS coding and auditing, with a strong focus on pediatric healthcare services and coding accuracy and payer claim processing. Job Duties:

• Validate the accuracy of ICD-10-CM, ICD-10-PCS, and DRG and APR group appropriateness, CPT and HCPCS inpatient patient and outpatient facility claims.
• Auditing inpatient claims to identify DRG codes that may have been over-assigned, ensuring accurate reimbursement aligned with regulatory and contractual guidelines.
• Identify and resolve complex coding discrepancies.
• Communicate complex coding findings to project lead and other cross functional teams.
• Be responsible and accountable for maintaining confidentiality, integrity, and availability of protected health information. Follow HIPAA security policies and procedures affecting your job, and report any suspected or actual violation or breach.

• Extensive knowledge of healthcare industry and experience in and around coding, billing, auditing, compliance and reimbursement for Inpatient and Outpatient facility.
• Must have extensive pediatric inpatient facility experience.
• 5 years of auditing facility inpatient and outpatient services with DRG and APR-DRG as well as familiarity with clinical documentation improvement practices.
• Extensive knowledge of current Official Coding Guidelines and Coding Clinic citations.
• Strong background in cost reduction strategies by ensuring correct claims payment and appropriate diagnosis-related group (DRG) assignment including familiarity with inpatient denial coding systems (e.g. CARC codes).
• Proficiency in coding software, electronic health record systems and familiar with how AI tools can assist in identifying over/under-assigned DRGs.
• High level proficiency in anatomy, physiology, disease process, and pharmacology.
• Detail oriented and deadline driven attitude.
• Ability to think critically and determine the best method for resolving challenges.
• Strong organizational skills, a strong sense of accountability, a proactive work ethic.

• RHIA, RHIT, or CCS from AHIMA and/or CPMA, CIC, COC from AAPC  

• Work volumes will vary depending upon projects

 AAPC Services is an Equal Opportunity Employer. This company does not and will not discriminate in employment and personnel practices on the basis of race, sex, age, handicap, religion, national origin or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above listed items.

We are an Equal Opportunity Employer. This company does not and will not discriminate in employment and personnel practices on the basis of race, sex, age, disability, religion, national origin, or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above-listed items.