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DRG Validation Auditor
DRG Validation Auditor

Roles and Responsibilities

The DRG Validation Auditor is a key member of the Penstock team responsible for ensuring that the DRG paid is fair and accurate, based on the documentation in the medical record, and the application of coding conventions and guidelines.

  • Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify discrepancies between the physician documentation, the clinical picture depicted in the record, the codes billed, and the resulting DRG.

  • Applies critical thinking to identify scenarios that require clinical input.

  • Appropriately uses industry-recognized references to support review findings, such as the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics.

  • Writes complete, clear, and accurate rationale to support determination, citing specific information from the record, as well as appropriate guidelines, policies, regulations, etc.

  • Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics.

  • Identifies and communicates new or expanded audit concepts and recovery opportunities.

  • Continuously considers the systems and processes involved with healthcare auditing (both internal and external) and communicates ideas for improvement.

  • Participates in the ongoing process of keeping the team abreast of coding updates and industry changes that impact DRG validation, as well as identifying internal training gaps/needs.

  • Communicates effectively with other health care and/or coding professionals, both internal and external, regarding case- or concept-specific details or questions and refers issues to management as appropriate.

  • Participates in project data analysis, reporting, and feedback.

  • Recommends improvements to processes, communications, operations, and client satisfaction.

  • Meets or exceeds Penstock’s performance and quality standards.

Qualifications and Education Requirements

We are looking for coders who share our passion for getting to the truth, and who share our commitment to improving the way healthcare is paid for.

  • Minimum of an Associate degree

  • Current AHIMA coding credential(s): RHIT, RHIA, or CCS

  • 3 or more years of ICD-10 inpatient coding or auditing experience (or demonstrated equivalent)

  • Comprehensive understanding of inpatient coding guidelines and Coding Clinic content

  • Strong current clinical knowledgebase

  • Working knowledge of Microsoft Word, Excel, and PowerPoint

  • Familiarity with Clinical Documentation improvement/Integrity practices

  • Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII

  • Ability to work independently, manage workload, and adapt to shifting priorities

  • Excellent communication skills, both written and oral

  • Must be able to work Eastern time zone hours

  • Must have a separate room with a lockable door for a home office to ensure absolute and continuous privacy while working

  • Must have access to high-speed internet for a home office.

Preferred Skills

  • Bachelor’s degree

  • 5 years of ICD-10 auditing and coding experience

  • CCS credential

  • CDIP or CCDS credential

  • CHDA credential

  • Nursing education and/or experience

  • Intermediate and expert-level Excel skills

  • SQL experience

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