DRG Validation Coding Auditor
- Experience
- Senior
- Employment
- Full-time
Open to US only. Set where you work from to check your eligibility.
No BS summary
Auditor for acute inpatient services, focusing on DRG validation. Requires 5+ years coding experience, 3+ in facility coding audit (DRG/APC). Must be proficient in EMRs, encoders, MS Office, and HIPAA. Bachelors degree or equivalent experience and at least one coding certification (CCS preferred) are mandatory. Remote, but requires travel as needed.
Core skills
Required skills
Optional skills
Required languages
Thank you for considering a career at Ensemble! Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. The Opportunity: CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement This position pays between $69,400 to $104,100 annually based on experience. Final compensation will be determined based on experience. The Inpatient/DRG Validation Coding Auditor performs documentation and coding audits for all acute inpatient services for clients. Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns. Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations. Has an extensive understanding of reimbursement guidelines, specifically related to DRG (MS, APR, Tricare, etc.) payment systems. Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. Ensures that the assigned DRG reflects the severity of the patient’s condition, and the resources used during their hospital stay. Assesses whether the clinical documentation supports the coded diagnoses and procedures. Verifies that the medical record adequately justifies the assigned DRG. Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities. Maintains productivity and quality goals as set by audit leaders. Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics. Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations. Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines. Completes required education through internal application, compliance training and other mandatory educational requirements. Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately. Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided. Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions. Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies. Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns. Shares and assists in development of concepts and or process improvement, tools, etc. Experience We Love: 5+ years of coding experience. 3+ years of facility coding audit experience (such as DRG and APC Validation). Proficiency in multiple EMR’s, encoders, and the Microsoft Office suite. Educated in HIPAA regulations; must maintain strict confidentiality of patient and client information. Consistently achieves quality and productivity standards. Ability to organize and complete work in a timely manner. Ability to read, write and effectively communicate in English. Ability to understand medical/surgical terminology. Above average written and verbal communication skills. Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences. This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require. Minimum Education: Bachelors Degree or Equivalent Experience Certification Required: Candidates must have and keep current at least one of the following professional certifications (CCS Preferred): CPC (Certified Professional Coder) CCS (Certified Coding Specialist) RHIA (Registered Health Information Administrator) RHIT (Registered Health Information Technician) #LI-HB1 #LI-REMOTE Join an award-winning company Five-time winner of “Best in KLAS” 2020-2022, 2024-2025 Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024 Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024 Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023 Energage Top Workplaces USA 2022-2024 Fortune Media Best Workplaces in Healthcare 2024 Monster Top Workplace for Remote Work 2024 Great Place to Work certified 2023-2024 Innovation Work-Life Flexibility Leadership Purpose + Values Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include: Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs. Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation. Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company. Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories. Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com . This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range. Employment Disclaimers – Ensemble
What you'll do
- Performs documentation and coding audits for all acute inpatient services for clients.
- Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements.
- Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns.
- Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations.
- Has an extensive understanding of reimbursement guidelines, specifically related to DRG (MS, APR, Tricare, etc.) payment systems.
- Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines.
- Ensures that the assigned DRG reflects the severity of the patient’s condition, and the resources used during their hospital stay.
- Assesses whether the clinical documentation supports the coded diagnoses and procedures.
- Verifies that the medical record adequately justifies the assigned DRG.
- Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders.
- Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities.
- Maintains productivity and quality goals as set by audit leaders.
- Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics.
- Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations.
- Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines.
- Completes required education through internal application, compliance training and other mandatory educational requirements.
- Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately.
- Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided.
- Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions.
- Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies.
- Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns.
- Shares and assists in development of concepts and or process improvement, tools, etc.
What they require
- 5+ years of coding experience.
- 3+ years of facility coding audit experience (such as DRG and APC Validation).
- Proficiency in multiple EMR’s, encoders, and the Microsoft Office suite.
- Educated in HIPAA regulations; must maintain strict confidentiality of patient and client information.
- Consistently achieves quality and productivity standards.
- Ability to organize and complete work in a timely manner.
- Ability to read, write and effectively communicate in English.
- Ability to understand medical/surgical terminology.
- Above average written and verbal communication skills.
- Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.
- This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
- Bachelors Degree or Equivalent Experience
- Candidates must have and keep current at least one of the following professional certifications (CCS Preferred): CPC (Certified Professional Coder) CCS (Certified Coding Specialist) RHIA (Registered Health Information Administrator) RHIT (Registered Health Information Technician)
Benefits
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
- Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
- Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
- Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
- Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups.
What people say about this company
3.4/ 5