DRG (Coding) Appeal Reviewer
Position Summary
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.
Under the direction of the DRG Operations Department leaders, the DRG Appeal Reviewer reviews and analyzes provider responses on denied/downgraded MS-DRG and APR-DRG claims to determine whether the downgraded DRG is substantiated after appeal and will construct a detailed response letter.
Responsibilities
Analyze and review inpatient claims following the Official Coding and Reporting Guidelines to validate the reported ICD-10-CM/PCS codes to ensure proper DRG assignment for accurate billing.
Demonstrates the ability to perform a comprehensive initial review as outlined in the standard operating procedures and departmental guides.
Construct professionally written and detailed responses to providers current coding and regulatory guidelines applicable to the downgraded claim.
Collaborates with physician reviewers, as needed.
Ability to prioritize and organize workload and complete tasks independently.
Required attendance of all departmental team meetings and/or training.
Work on other duties or tasks, as necessary.
Performance Expectations
Report productivity daily utilizing department productivity report.
Meet/exceed productivity expectations as outlined in the department productivity policy.
Maintains 95% accuracy in claim reviews.
Complies with organization policy and procedures.
Qualifications
Coding Certification required (at least one of the following is required and must be maintained as a condition of employment).
Registered Health Information Administrator (RHIA)
Registered Heath Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Inpatient Coder (CIC)
Candidates with a Registered Heath Information Technician (RHIT)
Other credential consideration:
Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) or Certified Professional Coder (CPC) will be considered but will need to obtain an inpatient coding certification (CCS or CIC) within 12 months of hire.
College level courses in medical terminology, anatomy, pathophysiology, pharmacology, and medical coding courses.
5+ years of experience in MS-DRG and APR-DRG coding experience through acute care inpatient coding, auditing, and/or payment integrity DRG Validation.
At least 2 years of appeal experience through the acute care setting and/or payment integrity DRG Validation.
Adherence to the Official Coding and Reporting guidelines, AHA Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
Requires working knowledge of applicable industry-based standards.
Proficiency in Outlook, Word, Excel, and other applications.
Excellent written and verbal communication skills.
Maintain professional credentialed status with approved continuing education programs.
Ability to work independently and can multi-task or transition to different tasks easily.
Remote Work Requirements
High speed internet (100 Mbps per person recommended) with secured WIFI.
A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
Must be able to sit and use a computer keyboard for extended periods of time.
Benefits and perks include:
Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
401(k) with Employer Match - Join the team and we will invest in your future
Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when youre not feeling well, to observe holidays.
Wellness - We care about your well-being. From Commuter Benefits to FSAs weve got you covered.
Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, were focused on your growth as a working professional.
Salary Range: $85,000- 90,000/ annually.
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At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.
Under the direction of the DRG Operations Department leaders, the DRG Appeal Reviewer reviews and analyzes provider responses on denied/downgraded MS-DRG and APR-DRG claims to determine whether the downgraded DRG is substantiated after appeal and will construct a detailed response letter.
Responsibilities
Analyze and review inpatient claims following the Official Coding and Reporting Guidelines to validate the reported ICD-10-CM/PCS codes to ensure proper DRG assignment for accurate billing.
Demonstrates the ability to perform a comprehensive initial review as outlined in the standard operating procedures and departmental guides.
Construct professionally written and detailed responses to providers current coding and regulatory guidelines applicable to the downgraded claim.
Collaborates with physician reviewers, as needed.
Ability to prioritize and organize workload and complete tasks independently.
Required attendance of all departmental team meetings and/or training.
Work on other duties or tasks, as necessary.
Performance Expectations
Report productivity daily utilizing department productivity report.
Meet/exceed productivity expectations as outlined in the department productivity policy.
Maintains 95% accuracy in claim reviews.
Complies with organization policy and procedures.
Qualifications
Coding Certification required (at least one of the following is required and must be maintained as a condition of employment).
Registered Health Information Administrator (RHIA)
Registered Heath Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Inpatient Coder (CIC)
Candidates with a Registered Heath Information Technician (RHIT)
Other credential consideration:
Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) or Certified Professional Coder (CPC) will be considered but will need to obtain an inpatient coding certification (CCS or CIC) within 12 months of hire.
College level courses in medical terminology, anatomy, pathophysiology, pharmacology, and medical coding courses.
5+ years of experience in MS-DRG and APR-DRG coding experience through acute care inpatient coding, auditing, and/or payment integrity DRG Validation.
At least 2 years of appeal experience through the acute care setting and/or payment integrity DRG Validation.
Adherence to the Official Coding and Reporting guidelines, AHA Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
Requires working knowledge of applicable industry-based standards.
Proficiency in Outlook, Word, Excel, and other applications.
Excellent written and verbal communication skills.
Maintain professional credentialed status with approved continuing education programs.
Ability to work independently and can multi-task or transition to different tasks easily.
Remote Work Requirements
High speed internet (100 Mbps per person recommended) with secured WIFI.
A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
Must be able to sit and use a computer keyboard for extended periods of time.
Benefits and perks include:
Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
401(k) with Employer Match - Join the team and we will invest in your future
Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when youre not feeling well, to observe holidays.
Wellness - We care about your well-being. From Commuter Benefits to FSAs weve got you covered.
Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, were focused on your growth as a working professional.
Salary Range: $85,000- 90,000/ annually.
mHHgKy4gFN
Apply Now