Job description

TREND Health Partners is a tech-enabled payment integrity company. Our mission is to facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving access to healthcare. We achieve this by aligning the common goals of payers and providers and fostering collaboration through a shared technology platform and seamless workflows. Joining TREND Health Partners means becoming part of a dynamic, growing organization that promotes a collaborative and innovative work environment. Our comprehensive compensation package includes competitive salaries, highly valued health insurance, a 401(k) plan with employer match, paid parental leave, and more. The Nurse Coder DRG Auditor III’s primary responsibility is to operate as a Subject Matter Expert.

Independently audit outpatient and inpatient claims applying coding guidelines while reviewing supporting medical documentation, completing appeal responses and communicating findings;
Independently validate and perform quality checks for other team members;
Execute strategic decision making authority, and support management with enterprise level recommendations.
Role and Responsibilities

Utilize coding guidelines and clinical guidelines to perform DRG or APC validation

Validate principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses and procedures utilizing the medical record

Evaluate short stay claims for medical necessity of an inpatient level of care

Apply CPT and ICD-10 guidelines

Apply policies, procedures, guidelines and regulations developed by Centers for Medicare and Medicaid Services (CMS), commercial payers, InterQual, MCG, and Trend Health Partners

Provide appeal responses for claims of the above types utilizing industry standards and company/client policies

Assist with new concept development

Assist with claim selection criteria

Assist with itemized bill review as needed

Maintain licensures, certifications and continuing education requirements

May require client communication to support findings

Independently apply and establish guidelines for others to apply coding guidelines

Performs quality checks for other team members

Qualifications

An active RN professional license in good standing

Clinical practice experience

Coding certification in good standing. Examples: CCS, CIC

Coding validation/auditing experience

Well-developed verbal and written communication skills coupled with recognizable organization

Ability to effectively prioritize tasks

Microsoft Office experience, specifically Excel

Preferred Skills

Appeals experience a plus

APR-DRG experience a plus

Client communication experience a plus

Concept development experience a plus

Claim selection experience a plus

Experience with machine learning/artificial intelligence a plus

Case Management and/or Utilization Review experience a plus

Clinical Documentation Improvement experience a plus

Itemized bill validation experience a plus

Quality Assurance experience a plus

Management experience a plus

Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) a plus

TruCode/TruBridge, 3M, WebStrat or similar experience a plus

Mental and Physical Demands

This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.

The nature of the work is sedentary, and the employee will be sitting most of the time.

Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.

Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

Related duties as assigned

This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.

Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.

Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.

Nurse Coder DRG Auditor III

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