Contractor DRG Validation Auditor

• 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.

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