Position Description

The DRG Validation Auditor is part of the DRG Validation Team and is responsible for reviewing medical records to ensure accurate coding and proper reimbursement for clinical services provided to members of Commercial and Government health plans.

The auditor reviews paid claims and identifies possible overpayments or underpayments on behalf of the client. These claims may come from various healthcare providers, including acute care hospitals, long-term acute care, rehabilitation centers, skilled nursing facilities, and other care settings.

Auditors receive thorough training to understand how to review medical records, apply correct coding guidelines, and use client-specific documentation formats. Ongoing education is also provided to keep up with changes in coding rules, audit processes, and reimbursement practices.

The review process may lead to adjustments in payment for previously billed services. Auditors use their coding knowledge and critical thinking to evaluate documentation and make informed decisions.

REQUIRED QUALIFICATIONS

• Holds current AHIMA credentials (RHIT, RHIA, or CCS); CCS preferred

• Minimum of 2-3 years of inpatient coding experience is required

• Strong knowledge of ICD-10-CM/PCS coding and DRG reimbursement

• Experience in training and mentoring junior coders is highly desirable

• Proficient in MS-DRG and APR-DRG reimbursement methodologies

• Demonstrates strong clinical validation and data analysis skills

• Skilled in using Microsoft Office (Outlook, Word, Excel) and Windows OS

• Ability to write clear, well-structured narrative reviews with proper grammar and punctuation

• Able to adapt to shifting priorities and meet productivity standards and deadlines

• Self-directed, detail-oriented, and passionate about continuous learning

• May be required to travel occasionally for training or on-site reviews

• Reject applicants with frequent job switching or serial job-hoppers

• Should be amenable to working on a hybrid setup in Taguig

DUTIES AND RESPONSIBILITIES:

• Reviews inpatient medical records to validate, assignment and sequencing of ICD-10 diagnosis and procedure codes, discharge status codes, Hospital Acquired Conditions (HACs), POA assignment, and DRG assignment.

• Provides a detailed rationale for every medical record review resulting in a DRG Review Results letter, including supporting references.

• Follows proper procedure for referral to Clinical Nurse Auditor or Physician Advisor, as applicable.

• Utilizes proper reference material, standards, and guidelines for coding.

• Provides input to the Edit Development team on claims selection criteria.

• Verifies data received from client and work to resolve discrepancies.

• If the contract requires onsite review, interacts with Providers and other personnel in a professional manner.

• Follows company policies and processes, completing Red Carpet, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.

• Communicates timely with Team Lead regarding illnesses, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.

• Complies with department standards regarding productivity and audit quality.

• Performs other duties as assigned.