DRG CVA RN Auditor - National Remote

$70,200 - $137,800/Yr

Optum - Eden Prairie, MN

Part-time,Full-time - Mid Level

Remote - Eden Prairie, MN

Insurance Carriers and Related Activities

About the position

As a Coding & Clinical Auditor / DRG Specialist RN at Optum, you will leverage your expertise in MS-DRG and APR-DRG coding methodologies to audit inpatient claims, ensuring accuracy in coding and reimbursement. This role involves validating ICD-10 codes and DRG assignments, identifying overpayments, and providing clear rationales for audit findings. You will work in a flexible telecommuting environment, contributing to improved health outcomes and advancing health equity on a global scale.

Responsibilities

• Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification.
• Utilize expert knowledge 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.
• Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate 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.
• Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment.
• Write 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 manage daily case review assignments, with a high emphasis on quality.
• Provide clinical support and expertise to the other investigative and analytical areas.
• Work in a high-volume production environment that is matrix driven.

Requirements

• Associate's Degree (or higher)
• Unrestricted RN (Registered Nurse) license
• CCS/CIC or willing to obtain certification 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
• 2+ years of ICD-10-CM coding experience 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)
• 2+ years of ICD-10-PCS coding experience including but not limited to: expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers.

Nice-to-haves

• 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.

Benefits

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)