DRG Revenue Integrity Auditor
3 days ago
About the Role
The DRG Revenue Integrity Auditor (DRG-A) is responsible for performing Diagnostic Related Group (DRG) validation and quality audits on inpatient charts. This role ensures that all reviewed charts accurately reflect the patient's true clinical picture, based on codes assigned by facility coders, and in compliance with federal regulations. The DRG-A applies ICD-10-CM/PCS coding standards, evaluates sequencing accuracy, and validates severity of illness (SOI), risk of mortality (ROM), Hierarchical Condition Category (HCC) capture, case mix index (CMI), and other coding factors.
Auditors use current clinical criteria, MCG, InterQual, payer clinical policy bulletins, CMS guidelines, NCDs, and LCDs to ensure compliance. They also support training, data analysis, and client reporting, while maintaining professional etiquette and protecting patient health information (PHI).
Responsibilities
- Perform DRG validation and quality audits on inpatient charts.
- Ensure accurate ICD-10-CM/PCS code sequencing, POA assignments, SOI, ROM, HCC capture, and CMI.
- Adhere to all coding guidelines and CDI best practices endorsed by ACDIS and AHIMA.
- Analyze records for query opportunities and appropriate code assignment.
- Maintain quality and productivity standards in chart reviews.
- Stay current with official coding guidelines, coding clinics, and clinical criteria.
- Provide training, shadowing, and support for new hires.
- Assist with project data analysis, reporting, and feedback for internal teams and clients.
- Protect patient privacy and confidentiality in compliance with AHIMA's Standards of Ethical Coding.
- Communicate openly and respectfully with coworkers to promote teamwork and knowledge sharing.
- Exhibit professionalism and strong communication skills when interacting with clients.
- Maintain professional credentials and knowledge of CDI, coding, reimbursement, and compliance issues through continuing education.
- Attend mandatory meetings and trainings.
- Audit client CDI programs, including query review and coding accuracy analysis.
- Manage company and EMR access credentials securely.
- Perform other duties as assigned by management.
- CCS coding credential from AHIMA.
- 5+ years of experience in an acute care setting or with a third-party vendor as a DRG Auditor or Clinical Documentation Specialist (CDS).
- Prior experience as a CDI/Coding Auditor preferred but not required.
- Experience with telecommuting and electronic medical record (EMR) systems.
- Proficiency in MS Word, Excel, Outlook, Teams, and other common workplace applications.
- Strong analytical and problem-solving skills.
- Ability to work with numbers and apply basic math skills.
- Strong team player with excellent collaboration skills.
- Ability to manage multiple diverse clients and projects simultaneously.
- Flexibility to switch between clients throughout the day and week.
- Ability to work independently with minimal supervision.
- Strong organizational skills to maintain and access multiple files efficiently.
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