Remote Clinical Denials & Appeals Auditor (RN)

EDUCATION: CDIP or CCDS required and RN Preferred. CCS, RHIA or RHIT preferred. CPMA (Certified Professional Medical Auditor) is a plus.

EXPERIENCE:

A minimum of three –five years ongoing inpatient CDI  experience in ICD-9-CM, ICD-10-CM/PCS and DRGs. 3-4 year’s Clinical Documentation high level review experience required, with experience in mortality risk, PSI, medical necessity HAC’s. A minimum of two years auditing experience.Must have recent/current Clinical Appeals  exp.  Coding appeals also strongly preferred.  Ideal candidate will have both in relation to Inpatient charges.  Must have exp writing successful Appeal Letters to payers on behalf of the Health System or Hospital

Performs inpatient coding DRG denial audits of RAC and non-RAC payer accounts, for the HIM Department at the Corporate office. Reviews patient records for accuracy in ICD-9-CM coding, ICD-10-CM/PCS, DRG assignment, present on admission indicators (POA), discharge disposition and any other pertinent data needed to capture coding accuracy. Provides audit feedback via the auditing process to pertinent parties, i.e. HIM Director, Corporate Coding Manager, etc.. Assists in preparation of the monthly and quarterly denials audit reports. Applied knowledge of medical terminology, pathophysiology, and pharmacology. Demonstrates tested data quality and integrity skills.

ESSENTIAL DUTIES:

Performs inpatient coding denial review using ICD-9-CM, ICD-10-CM/PCS, DRG validation (3Mcoding software) utilizing appropriate coding references for CHS hospitals via scanned, electronic and hybrid medical records.
Will utilize hospital abstracting system for coding validation when applicable.
Prepares preliminary results for review by the requesting party.
Reviews DRG change disagreements with the Director, Coding Denials and Appeals.
Assists in preparation of the final quarterly audit reports for Division VPs, AVPs, facility CEOs, CFOs, Regional HIM Directors, VP of HIIM.
Provides coder education via email and phone on all audits and uses applicable coding references.
Maintains productivity levels set forth by the HIIM Department and interdepartmental policy while maintaining a 97% accuracy rate by third party auditors.
Consults with Director, Coding Denials and Appeals during any audit discrepancies.
Attends coding workshops as necessary to maintain coding credentials.
Keeps abreast of regulatory changes affecting coding rules and regulations.
Maintains proficiency in the Official Coding Guidelines for coding and reporting and the AHA Coding Clinics.
Other duties as assigned by Director, Coding Denials and Appeals

Thorough knowledge of the related inpatient prospective payment systems (IPPS)
Experience in working DRG coding denials and writing appeal letters to government and non-government payers
Experience preserving coding integrity based on Coding Guidelines, Coding Clinic and appropriate coding references and resources
Broad knowledge of pharmacology indications for drug usage and related adverse reactions
Knowledge of anatomy, physiology and medical terminology
Understanding of coding practices and official guidelines