Auditor Project Lead-DRG Validation

Summary

Join AAPC as a remote DRG validation auditor specializing in coding-related denials, reimbursement audits, and clinical documentation improvement. You will be part of a team using machine learning software to enhance data quality and medical coding practices. This role offers the chance to contribute to the development of auditing software and work in a dynamic, high-performing team. The ideal candidate possesses inpatient and outpatient coding/auditing experience, particularly in pediatric healthcare services. You will manage DRG validation projects, validate claim accuracy, identify coding discrepancies, and provide expert client services. This position requires extensive knowledge of healthcare coding, billing, auditing, and compliance, along with specific certifications and a strong understanding of DRG assignment and denial coding systems.

Requirements

• 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
• 8 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
• Ability to think critically and determine the best method for resolving challenges
• Excellent organizational skills, a strong sense of accountability, a proactive work ethic and a collaborative approach to working with cross-functional teams
• RHIA, RHIT, or CCS from AHIMA and/or CPMA, CIC, COC from AAPC

Responsibilities

• Manage DRG validation projects including client expectations, collaboration with engineers and product team as well as oversee contract auditors
• 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
• Provide expert client services and communicate complex coding findings
• 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

Benefits

• Competitive compensation commensurate with experience
• Comprehensive benefits package including medical, dental and vision insurance
• 401(k) retirement plan
• Health Savings Account (HSA)
• Generous PTO and holiday pay