FAR DRG CVA RN Auditor
About the position
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. In this position as a Coding & Clinical Auditor / DRG Specialist RN, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You'll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.
Responsibilities
Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
,
Identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
,
Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing
,
Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
,
Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
,
Maintain and manage daily case review assignments, with a high emphasis on quality
,
Provide clinical support and expertise to the other investigative and analytical areas
,
Work in a high-volume production environment that is matrix driven
Requirements
Associate's Degree (or higher)
,
Unrestricted RN (Registered Nurse) license
,
CCS/CIC or willing to obtain certification within 6 months of hire
,
3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
,
2+ years of ICD-10-CM coding experience including expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
,
2+ years of ICD-10-PCS coding experience including expert knowledge of the structural components of PCS including selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers
Nice-to-haves
Experience with prior DRG concurrent and/or retrospective overpayment identification audits
,
Experience with readmission reviews of claims
,
Experience with DRG encoder tools (ex. 3M)
,
Experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
,
Healthcare claims experience
,
Managed care experience
,
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Benefits
Comprehensive benefits package
,
Incentive and recognition programs
,
Equity stock purchase
,
401k contribution
Apply Now
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. In this position as a Coding & Clinical Auditor / DRG Specialist RN, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You'll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.
Responsibilities
Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
,
Identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
,
Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing
,
Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
,
Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
,
Maintain and manage daily case review assignments, with a high emphasis on quality
,
Provide clinical support and expertise to the other investigative and analytical areas
,
Work in a high-volume production environment that is matrix driven
Requirements
Associate's Degree (or higher)
,
Unrestricted RN (Registered Nurse) license
,
CCS/CIC or willing to obtain certification within 6 months of hire
,
3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
,
2+ years of ICD-10-CM coding experience including expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
,
2+ years of ICD-10-PCS coding experience including expert knowledge of the structural components of PCS including selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers
Nice-to-haves
Experience with prior DRG concurrent and/or retrospective overpayment identification audits
,
Experience with readmission reviews of claims
,
Experience with DRG encoder tools (ex. 3M)
,
Experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry
,
Healthcare claims experience
,
Managed care experience
,
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Benefits
Comprehensive benefits package
,
Incentive and recognition programs
,
Equity stock purchase
,
401k contribution
Apply Now