DRG Validation Specialist
Valenz
- Phoenix, AZ
- Permanent
- Full-time
About Our Opportunity
The DRG Validation Specialist (aka Clinical Bill Review Analyst, DRG) will conduct clinical audits including, but not limited to, Diagnosis Related Grouper Validation (DRG), medical record billing discrepancies, and prior authorization discrepancies per policies. The DRG Analyst is responsible for verifying the accuracy of DRG claims submitted for review by selecting claims for medical record reviews in accordance with pre-selection criteria, billing trends, and supporting documentation. The Auditor will collaborate with various business units, including ProteKHt, Claims, Care, and Network Development, as well as with external resources. The successful candidate must be capable of building and maintaining strong working relationships with these key internal and external constituents and must be able to adjust tasks to daily priorities.Things You’ll Do Here:
- Identifies correct billing and savings on claims by running the codes through internal and external programs such as RevCycle Pro/ Encoder Pro/SuperCoder.
- Develop P&P’s in conjunction with the Director and Supervisor.
- Monitor existing/emerging trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention or result in additional savings.
- Identifies compliance risks and financial opportunities based on chart reviews.
- Performs concurrent review of hospital bills to document unbilled, underbilled, and overbilled items/services.
- Educate stakeholders on post-audit findings and close audits in a timely manner.
- Communicates all findings to clients by providing a DRG Report that can be reviewed with clients at their request.
- Works collaboratively with the Negotiation team to resolve claim issues and obtain additional discounts.
- Communicates with providers to query or to resolve billing discrepancies and respond to appeals.
- Educates staff and clients on any updated information on codes/edits.
- Maintains a consistent department turnaround time.
- Assists Sales Managers in their marketing of the program.
- Assists direct supervisor in the achievement of departmental goals and suggestions that will increase revenue relating to Bill Review.
- Complies with/supports HIPAA standards
- Identify possible fraud and abuse, document billing errors, and benefit-cost management and savings opportunities.
- 3-5 years of auditing, claims, review, and/or billing experience with a healthcare organization required
- In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT, APR-DRG, MS-DRG codes, and DRG grouping systems and Plan benefit designs.
- Bill and concurrent review experience
- DRG Validation experience
- Line Charge Verification experience
- Working knowledge of industry coding, ICD-10, CPT, HCPCS and Revenue codes etc.
- Has experience with Microsoft Office applications.
- Excellent communication skills, both verbal and written.
- Working knowledge of Health Insurance, Medicare guidelines, and various healthcare programs
- Knowledge of CMS guidelines
- Bachelor’s degree in Healthcare Administration, Business Administration, or a related field.
- CPC and CIC certification preferred
- Active Certified coder (RHIA, RHIT, CPC, CIC, COC or CCS) required; candidate would need to maintain active certification.
- Work Environment: You’ll need a quiet workspace that is free from distractions.
- Technology: Reliable internet connection—if you can use streaming services, you’re good to go!
- Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software.
- Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.
- Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
- Spending account options: HSA, FSA, and DCFSA
- 401K with company match and immediate vesting
- Flexible working environment
- Generous Paid Time Off to include vacation, sick leave, and paid holidays
- Employee Assistance Program that includes professional counseling, referrals, and additional services
- Paid maternity and paternity leave
- Pet insurance
- Employee discounts on phone plans, car rentals and computers
- Community giveback opportunities, including paid time off for philanthropic endeavors