- Perform comprehensive inpatient DRG validation reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.
- Based on the evidence presented in the medical records, determine, and record the appropriate (revised) Diagnosis Codes, Procedure Codes and Discharge Status Code applicable to the claim.Using the revised codes, regroup the claim using provided software to determine the 'new DRG' Where the regrouped 'new DRG' differs from what was originally claimed by the provider, write a customer facing 'rationale' or 'findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review
- Document all aspect of audits including uploading all provider communications, clinical rationale, and/or financial research
- Identify new DRG coding concepts to expand the DRG product.
- Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
- Meet and/or exceed all internal and department productivity and quality standards
- Recommend new methods to improve departmental procedures
- Achieve and maintain personal production and savings quota
- Maintain awareness of and ensure adherence to Zelis standards regarding privacy
- Registered Nurse licensure required
- Inpatient Coding Certification required (i.e. CCS, CIC, RHIA, RHIT)
- 3-5 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims required
- Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
- Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
- Understanding of hospital coding and billing rules
- Clinical skills to evaluate appropriate Medical Record Coding
- Experience conducting root cause analysis and identifying solutions
- Strong organization skills with attention to detail
- Outstanding verbal and written communication skills
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DRG Nurse Reviewer - St. Petersburg, United States - Zelis
Description
Position Overview
:The DRG Validation Nurse Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest possible savings for clients.
Key Responsibilities:
Skills, Knowledge, and Experience:
