Payment Integrity Analyst II

2 weeks ago

Texas, United States CorVel Corporation Full time

CERIS in Fort Worth, Texas is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) QC Clinical Auditor will be responsible for performing quality control DRG validation (clinical/coding) reviews of internal audit team reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination, as well as communicating missed or incorrect information to the auditors in a professional manner. Experience using, ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures.

Job Duties and Responsibilities:

  • The Quality Control Clinical Auditor will review previously audited claims for any missed opportunities or errors.
  • The Quality Control Clinical Auditor will review all opportunities sent to the customers for complete and correct information.
  • The Quality Control Clinical Auditor will check for physician's notes supporting the DRGs assigned.
  • Reviewing medical records to determine accuracy of billing through verification of coding and supporting clinical documentation.
  • Reviewing previously conducted audits to ensure accurate coding and identifying potential savings.
  • Demonstrated expert knowledge of, ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative.
  • Able to clearly, accurately, and professionally communicate coding/clinical information back to the Audit team or the customer, using correct grammar, spelling, sentence structure, and meet template format requirements.

Qualifications:

  • Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan. National Coding Certification required through either AHIMA (preferred) or AAPC.
  • RN license is preferred but not required.
  • Extensive hands-on ICD-10 CM / PCS experience required.
  • Proficient in both MS and APR DRG methodology preferred.
  • Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations.
  • Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments.
  • Proficient in Medicare and CMS guidelines
  • Extreme attention to detail.
  • Must possess problem solving, critical thinking skills.
  • Minimal typing experience.
  • Effective and professional communication skills, both verbal and written.
  • Ability to think and work independently, while working in an overall team environment.
  • Ability to work in a fast paced/production environment.
  • Proficient in Microsoft Office Suite.
  • Other duties as assigned

About CERiS

CERiS, a division of CorVel Corporation, a certified Great Place to Work Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

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