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DRG Coding and Clinical Validation RN Auditor

3 months ago

Eden Prairie, United States Optum Full time

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.


In this position as a Coding & Clinical Auditor / DRG Specialist RN, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings.


You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.


Primary Responsibilities:

  • Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
  • Expert knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
  • Must be fluent in the application of current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations, in addition to demonstrating working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
  • Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing
  • Solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
  • Writes clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
  • Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
  • Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements
  • Maintain and manages daily case review assignments, with a high emphasis on quality
  • Provide clinical support and expertise to the other investigative and analytical areas
  • Will be working in a high-volume production environment that is matrix driven


You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Unrestricted RN (registered nurse)
  • CCS/CIC or will obtain within 6 months of hire
  • 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
  • Expert knowledge of ICD -10-CM coding including but not limited to; expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
  • Expert knowledge of ICD-10-PCS coding including but not limited to; expert knowledge of the structural components of PCS including but not limited to; selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers


Preferred Qualifications:

  • Experience with prior DRG concurrent and/or retrospective overpayment identification audits
  • Experience with readmission reviews of claims
  • Experience with DRG encoder tools (ex. 3M)
  • Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
  • Healthcare claims experience
  • Managed care experience
  • Knowledge of health insurance business, industry terminology, and regulatory guidelines

Soft Skills:

  • Ability to use a Windows PC with the ability to utilize multiple applications at the same time
  • Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail
  • Ability to work independently in a remote environment and deliver exceptional results
  • Excellent time management and work prioritization skills

Physical Requirements and Work Environment:

  • Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer
  • Have a secluded office area in which to perform job duties during the work day
  • Have reliable high - speed internet access and a work environment free from distractions


*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy


California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.


At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.