Inpatient DRG Validation Auditor

Disclaimer: This is a 1099 independent contractor position requiring a minimum commitment of 30 hours per week. The contract term is one year, with the option to renew.

Role and Responsibilities​ 

The DRG Validation Auditor is a valued member of the Penstock Audit team, responsible for reviewing inpatient claims and ensuring that the DRG paid is fair and accurate, based on the documentation in the medical record and the application of ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, policies, and Coding Clinic advice. The DRG Validation Auditor upholds the standards of honesty, excellence, and innovation that are central to the Penstock mission. 

• Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify discrepancies between the physician documentation, the clinical picture depicted in the record, the codes billed, and the resulting DRG 

• Appropriately uses industry-recognized references to support review findings, including the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics 

• Writes complete, clear, and accurate rationale to support audit determinations, citing specific information from the record, and referencing appropriate guidelines, policies, regulations, and/or Coding advice 

• Keeps abreast of coding, clinical, regulatory, and other industry changes that impact Penstock auditing and/or that suggest new audit opportunities 

• Maintains focus on the identification and development of new audit concepts 

• Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels 

• Participates in focused training to learn new auditing skills across a myriad of clinical and coding scenarios 

• Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate 

• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers  

• Serves as a Payment Integrity subject matter expert for Penstock team members and for the Goodroot organization as a whole 

• Meets or exceeds Penstock’s performance and quality standards. 

​​Qualifications and Education Requirements​ 

• Completion and passing of the Revu Healthcare inpatient coding assessment
  
• Must have both payer and provider experience
  
• Must have clinical validation experience
• Must be able to meet for weekly meetings on Mondays at 6PM ET
• Must be able to commit to 40 hours minimum weekly
• Must hold active AHIMA coding credential(s): RHIT, RHIA, or CCS 
  
• Must hold active Clinical Validation credential(s):  CDIP, CCDS, or CDEI 
  
  
• Minimum of an associate degree 

• 3 or more years of ICD-10 inpatient coding experience 

• 3 or more years of clinical experience in a healthcare facility setting 

• 3 or more years of auditing experience (or demonstrated equivalent) 

• Comprehensive understanding of ICD-10-CM Inpatient Coding Guidelines, AHA Coding Clinic, and DRG grouping mechanics 

• Strong current clinical knowledgebase 

• Familiarity with Clinical Documentation Integrity practices  

• Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII 

• Ability to conduct independent research using credible sources 

• Demonstrated working knowledge of Microsoft Word, Excel, and PowerPoint 

• Ability to apply critical thinking skills to record reviews 

• Ability to work independently, manage workload, and adapt to shifting priorities 

• Willingness to adapt and learn new auditing skills across a myriad of coding and clinical scenarios 

• Excellent communication skills, both oral and written 

• Comfortable working in an ever-changing fast paced environment 

• Able to work Eastern time zone hours  

• Secure and private home office with reliable high-speed internet connection 

​​

Preferred Skills​ 

• Bachelor’s degree in Nursing

• 5+ years of inpatient ICD-10 coding and auditing experience 

• 5+ years of relevant auditing (clinical validation and medical necessity) experience 

• AHIMA/AAPC Coding Certification (RHIA, RHIT, CCS, CPC, CPC-H), AHIMA/ACDIS Clinical Documentation Certification (CDIP, CCDS), or Clinical Documentation Integrity experience