DRG Clinical Auditor

JOB SUMMARY: This role provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. In this role, incumbent will perform itemized bill reviews to identify billing abnormalities, unbundling, questionable billing practices and improper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity. JOB ROLES AND RESPONSIBILITIES: 1. Review and analyze complex inpatient and outpatient charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type including any additional information perceived as unbundled items and/or inappropriate charges. 2. Documents audit results and updates systems accordingly. 3. Assist management in the daily operations and processes within the department. 4. Design and participate in the clinical and coding education of coders, negotiators, and physicians. This includes orientation, training and mentoring of new and existing staff. 5. Identify opportunities for recovery and avoidance. Researches opportunities to better control overpayments and presents ideas to management. 6. Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research. 7. Provide general support to clinical team members, serving as a resource and subject matter expert (SME). 8. Monitors turnaround times for multiple applications and provides suggestions for process efficiencies. 9. Uses independent decision-making skills to review itemized bills after business hours to meet deadlines. 10. Apply national coding standards and regulations to claims billed. 11. Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed. 12. Collaborate with physician and analytics teams to create, enhance or suggest new coding edits, claim factors, guidelines and other applicable reference materials. 13. Monitor, research, and summarize trends, coding practices, and regulatory changes. 14. Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed. 15. Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner. 16. Evaluate performance of both newly hired and existing staff. . 17. Assist with education of staff as it relates to claims, suggest additional negotiation talking points or tools, develop instructional design, when applicable and communicate overall industry or regulatory changes which affect the department. 18. Partner with management to drive department goals and objectives. 19. Collaborate, coordinate, and communicate across disciplines and departments. 20. Ensure compliance with HIPAA regulations and requirements. 21. Demonstrate commitment to the Company's core values. 22. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role. 23. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary. Job Scope: This position works independently with minimal supervision in order to complete the outlined responsibilities. The incumbent balances several projects at a time and work is varied and complex. More complex issues are referred to higher levels. The incumbent follows established procedures and uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the job. COMPENSATION The salary range for this position is $75k-$80k annually. Specific offers take into account a candidate’s education, experience and skills, as well as the candidate’s work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity. JOB REQUIREMENTS (Education, Experience, and Training): * Minimum high school diploma along with five (5) years' experience in-line item bill review. Completion of educational curriculum required of a medical license or coding certification is also required. Bachelors' degree in a related field and at least five (5) years' of coding experience are both highly preferred. Extensive knowledge of inpatient/outpatient hospital billing including UB-04s, revenue codes, itemization of charges, CPT codes, HCPCS codes, ICD-10 diagnoses and procedure codes. * Strong medical background to identify inappropriate charges. * Extensive knowledge of DRG/APCs. * Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria and applicable industry standards. * Knowledge of commonly used medical data resources such as MDR, Medical Fees in the US, etc. * Auditing and health information management experience in a healthcare setting. * Required licensures, professional certifications, and/or Board certifications as applicable. * Experience with professional and facility contract interpretation. * Experience and proficiency using MS Office Suites: Excel, Outlook and PowerPoint. Visio helpful. * Excellent communication (written, verbal and listening), interpersonal, organizational, time-management, analytical, problem-solving, trouble-shooting, customer service skills. * Ability to develop educational materials and job aids pertaining to coding and claims. * Ability to work evening or weekend hours as needed to meet deadlines. * Ability to handle multiple tasks in a fast paced environment. * Ability to meet individual and team goals, deadlines and work standards. * Ability to apply independent judgment and determine appropriate course of action. * Ability to read and abstract medical records. * Knowledge of medical terminology, anatomy, and physiology. * Ability to interact and discuss results with providers. * Ability to lead, teach, mentor others, and facilitate a learning environment. * Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone. BENEFITS We realize that our employees are instrumental to our success, and we reward them accordingly with very competitive compensation and benefits packages, an incentive bonus program, as well as recognition and awards programs. Our work environment is friendly and supportive, and we offer flexible schedules whenever possible, as well as a wide range of live and web-based professional development and educational programs to prepare you for advancement opportunities. Your benefits will include: Medical, dental and vision coverage with low deductible & copay Life insurance Short and long-term disability Paid Parental Leave 401(k) + match Employee Stock Purchase Plan Generous Paid Time Off – accrued based on years of service WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service 10 paid company holidays Tuition reimbursement Flexible Spending Account Employee Assistance Program Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits. EEO STATEMENT Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status. If you would like more information on your EEO rights under the law, please click here . APPLICATION DEADLINE We will generally accept applications for at least 5 calendar days from the posting date or as long as the job remains posted. #LI-AN1