DRG Denials Auditor

Job Summary

The DRG Denials Auditor conducts hospital inpatient DRG denial audits for both RAC and non-RAC accounts, reviewing patient records for accuracy in ICD-10-CM/PCS coding, DRG assignments, and supporting clinical documentation. This includes evaluating present on admission (POA) indicators, discharge disposition, and any other relevant data to ensure coding accuracy. The auditor is also responsible for writing and defending appeal letters to payers with a strong attention to detail. Additionally, the auditor provides audit feedback to relevant parties, including coders and coding managers, to improve coding practices and compliance.

Essential Functions

• Performs inpatient denial reviews using ICD-10-CM/PCS and DRG validation utilizing appropriate coding references for CHS hospitals via scanned, electronic and hybrid medical records. Based on review findings, writes appeal letters to include supporting documentation.
• Utilizes hospital abstracting system for coding validation when applicable with access to the 3M encoder.
• Captures detailed data on reason for the denial and appeal status.
• Consults with Coordinator and/or Director, Coding Denials and Appeals during any audit discrepancies.
• Attends coding education to include regulatory change updates and changes affecting coding rules and/or DRG assignments.
• Maintains productivity levels set forth by the HIIM Department and interdepartmental policy with periodic quality monitoring and evaluation of work products by the Coordinator and/or Director, Coding Denials and Appeals.
• Partners with peers and Director to develop coder education based on findings.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• H.S. Diploma or GED required
• Other Medical Coding Program preferred
• Associate Degree Health Information Management or related field preferred
• 3-5 years Inpatient acute care hospital coding experience required
• 2-4 years Inpatient acute care hospital coding audit experience preferred
• 1-2 years Clinical Documentation Improvement or other clinical experience preferred

Knowledge, Skills and Abilities

• Experience with virtual desktop image, electronic medical record systems, encoding systems as well as word processing and spreadsheet software.
• Extensive knowledge of clinical disease processes, medical terminology, pathophysiology, and pharmacology.
• High degree of accuracy.
• Must preserve confidentiality of health information.
• Strong communication and organizational skills.

Licenses and Certifications

• CRNP, LPN, RN, MD, PA, or DO preferred
• CCS-Certified Coding Specialist required or
• RHIT - Registered Health Information Technician required or
• RHIA - Registered Health Information Administrator required or
• CDIP - Clinical Documentation Improvement Professional required or
• CCDS - Certified Clinical Documentation Specialist required