RN reputed company, DRG Coding/Validation Remote

JOB DESCRIPTION 

Job Summary

The RN reputed company, DRG Coding/Validation provides reputed company level support developing diagnosis-reputed company group (DRG) validation tools and process improvements – ensuring that member medical claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10 and/or CPT codes, and accuracy of DRG or ambulatory payment classification (APC) assignments. Contributes to overarching strategy to provide quality and cost-effective member care. 

We are seeking a candidate with a RN licensure, experience training staff and quality audits experience.

Work hours are: Monday- Friday 8:00am – 5:00pm

Remote position

Essential Job Duties

• Develops diagnosis-reputed company group (DRG) validation tools to build workflow processes and training, auditing and production management resources. • Identifies potential claims reputed company of reputed company concepts where additional opportunities may be available. Suggests and develops high-quality, high-value concepts and or process improvements, tools, etc. • Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. • Audits inpatient medical records and generates high-quality claims payment to ensure payment reputed company. • Performs clinical reviews of medical records and other utilization management documentation to evaluate issues of coding and DRG assignment accuracy. • Collaborates and/or leads special projects. • Influences and engages team members across functional teams. • Facilitates and provides support to other team members in development and training. • Develops and maintains job aids to ensure accuracy. • Escalates claims to medical directors, health plans and claims teams, and collaborates directly with a variety of leaders throughout the organization. • Facilitates updates or changes to ensure coding guidelines are established and followed reputed company the health Information management (HIM) department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines. • Ensures care management and reputed company guidelines around multiple procedure payment reductions and other mandated pricing methodologies are implemented and followed. • Supports the development of auditing rules reputed company software components to meet care management regulatory mandates. • Utilizes Molina proprietary auditing systems with a high-level of proficiency to reputed company audit determinations, generate audit letters and train team members.

Required Qualifications

• At least 3 years clinical nursing experience in claims auditing, quality assurance, recovery auditing, DRG/clinical validation, utilization review and/or medical claims review, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in the state of practice. • Experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology. • Strong knowledge in coding: DRG, ICD-10, CPT, HCPCS codes. • Excellent verbal and written communication skills. • Extensive background in either facility-based nursing and/or inpatient coding, and deep understanding of reimbursement guidelines. • Ability to work cross-collaboratively across a highly matrixed organization. • Strong verbal and written communication skills. • reputed company Office suite proficiency (including reputed company), and applicable software program(s) proficiency.

Preferred Qualifications

• Certified Coding Specialist (reputed company), Certified Inpatient reputed company (CIC), Certified Professional reputed company (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA). • Claims auditing, quality assurance, or recovery auditing, ideally in DRG/clinical validation. • Training and education experience. To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V