Diagnosis Related Group Auditor

Overview:

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Diagnosis Related Group (DRG) Auditor is responsible for auditing clinical documentation that supports code assignment for compliance with billing regulations, this includes compliance with the Conditions of Participation for CMS. The DRG auditor is responsible for ensuring coding accuracy, coding consistency and efficiency in filing of inpatient claims. Collaborates with the Clinical Documentation Quality Liaison to assist in reviewing quality initiatives directed at system-wide quality indicators (i.e. Mortality, Patient Safety Indicators [PSI], Hospital Acquired Conditions, Severe Maternal Morbidity, etc.) and clinical evidence to support Diagnosis-related group (DRG), principal diagnosis, and secondary diagnoses assignments. All duties are performed across the Hackensack Meridian Health (HMH) network.

This is a 100% remote position and weekends are as needed. 

A day in the life of a Diagnosis Related Group (DRG) Auditor at Hackensack Meridian Health includes:

• Performs data quality reviews on Inpatient Clinical Documentation Improvement (CDMP) records.
• Validates the (International Classification of Diseases 10th Diagnosis & Procedure Coding System) ICD-10-CM codes, DRG group appropriateness, audits for missed secondary diagnoses and procedures, and ensures compliance with all DRG mandates and reporting requirements.
• Monitors Medicare and other DRG payment bulletins and manuals and reviews the current Office of Inspector General work plans for DRG risks.
• Monitors inpatient case mix reports and the top 25 assigned DRG in the facility to identify patterns, trends, and variations in the facility's frequently assigned DRG groups.
• Evaluates the quality of clinical documentation in conjunction with the Clinical Documentation Department nursing staff to spot incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payments.
• Brings identified concerns to medical staff and other departments for action plan development and resolution.
• Provides or arranges for training of facility healthcare professionals including physicians in use of coding guidelines and practices, proper documentation techniques, medical technology, and disease processes as it relates to DRG and other clinical data quality management factors.
• Reports all relevant information to the facility Compliance Committee on a quarterly basis.
• Provides feedback to CDMP Manager regarding CDMP nurses for performance evaluation purposes.
• Conducts regularly scheduled in-service education for CDMP based upon the data quality reviews of CDMP DRG assignment and failures in the coding query process.
• Informs CDMP staff of changes to ICD10 coding and DRG grouper logic.
• Provides feedback to coders regarding their coding and grouping errors.
• Responsible for re-coding/ reviewing consecutive accounts for Medicare 24 hour readmit accounts, Medicaid 7 day readmit accounts, and Medicare 3 day rule accounts as indicated by Case Management/Admissions.
• Daily monitoring of the PFS communication WQs and address accounts referred to coding for review.
• Makes coding changes and performs account activity to send to Finance for rebilling.
• Performs coding quality reviews as needed on accounts referred to coding by auditing companies, Finance/PFS, and/or ancillary/external departments.
• Reviews CDI quality liaison recommendations as it relates to mortality, PSI/HAC, POA and risk adjustment codes and makes changes as needed in compliance with coding guidelines.
• Provides continuous support for HMH network as listed above as well as other duties and/or projects as assigned.
• Other duties asn/or projects as assigned
• Adheres to HMH Organizational competencies and standards of behavior.

Education, Knowledge, Skills and Abilities Required:

• Bachelor's Degree or equivalent years of experience.
• Formal Health Information Management (HIM) education.
• Minimum of 5 years progressive coding review in ICD-10-CM and DRG methodologies.
• Knowledge of POA/HAC, PSI and core measures.
• Knowledge in data collection.
• Good oral and written communication skills.
• Excellent written and verbal communication skills.
• Proficient computer skills including but not limited to Microsoft Office and Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

• Knowledge of the DRG structure and regulatory requirements.
• Experience in claims processing and data management responsibilities.
• Knowledge in Patient Safety/Quality Management.
• Auditing experience.

Licenses and Certifications Required:

• Certified Coding Specialist.

Licenses and Certifications Preferred:

• Registered Health Information Administrator Certification or Registered Health Information Technician.

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!