DRG Validation Coding Auditor
Ensemble Health Partners · United States
- Hybrid
- Full-time
- $86,700 / year
- United States
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Job highlights
- Audit inpatient coding and documentation for accuracy.
- Optimize reimbursement through compliant coding practices.
- Analyze medical records and identify coding issues.
- Collaborate with CDI specialists for documentation improvement.
- Maintain high productivity and quality audit standards.
About the role
About Ensemble Health Partners
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 Role of DRG Validation Coding Auditor
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 a 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.
- Uses 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.
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)
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
Why Ensemble?
- 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.
Key skills/competency
- DRG Validation
- Coding Auditing
- Inpatient Coding
- ICD-10-CM/PCS
- Reimbursement Guidelines
- Clinical Documentation Integrity (CDI)
- Medical Records Review
- Compliance
- Revenue Cycle Management
- Healthcare Auditing
Skills & topics
- DRG Validation
- Coding Auditor
- Inpatient Coding
- ICD-10-CM/PCS
- Reimbursement
- Revenue Cycle Management
- Healthcare Auditing
- Clinical Documentation Integrity
- Medical Coding
- Compliance Specialist
How to get hired
- Tailor your resume: Highlight your 5+ years of coding and 3+ years of DRG/APC audit experience, emphasizing your certifications (CCS, CPC, RHIA, RHIT).
- Showcase your expertise: Detail your proficiency with EMRs, encoders, Microsoft Office, and your understanding of HIPAA regulations and ICD-10 coding.
- Quantify achievements: Use numbers to demonstrate how you've met or exceeded quality and productivity standards in previous roles.
- Address remote work: Mention your willingness to travel for client needs, as this is a remote position with on-site requirements.
- Prepare for interviews: Be ready to discuss your knowledge of DRG payment systems (MS, APR, Tricare) and your approach to clinical documentation reviews.
Technical preparation
Master ICD-10-CM/PCS coding guidelines thoroughly.,Practice auditing DRG assignments (MS, APR, Tricare).,Become proficient with EMRs and encoders.,Understand HIPAA and data privacy requirements.
Behavioral questions
Describe a complex coding error you identified.,How do you ensure accuracy in your audits?,How do you handle feedback and provide education?,How do you stay updated on coding regulations?
Frequently asked questions
- What is the salary range for a DRG Validation Coding Auditor at Ensemble Health Partners?
- The salary range for a DRG Validation Coding Auditor at Ensemble Health Partners is between $69,400 to $104,100 annually, with the final compensation determined by your relevant experience.
- What certifications are required for the DRG Validation Coding Auditor role?
- Candidates must hold at least one current professional certification, such as CPC, CCS (preferred), RHIA, or RHIT. Maintaining these certifications and obtaining CEUs is essential.
- Is this a fully remote position?
- This is a remote position, but candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
- What are the key responsibilities of an Inpatient/DRG Validation Coding Auditor?
- Key responsibilities include performing documentation and coding audits for acute inpatient services, identifying coding errors, optimizing reimbursement, interpreting medical records, and ensuring compliance with coding guidelines.
- What kind of experience does Ensemble Health Partners look for in a DRG Validation Coding Auditor?
- Ensemble Health Partners seeks candidates with 5+ years of coding experience and at least 3 years of facility coding audit experience, specifically in DRG and APC validation. Proficiency in EMRs, encoders, and Microsoft Office is also important.
- What is the O.N.E Purpose at Ensemble Health Partners?
- The O.N.E Purpose at Ensemble Health Partners stands for Customer Obsession, Embracing New Ideas, and Striving for Excellence, guiding their approach to client service, innovation, and operational performance.
- What benefits does Ensemble Health Partners offer its associates?
- Ensemble Health Partners offers a comprehensive benefits package including healthcare, time off, retirement, and well-being programs. They also provide paid certifications, tuition reimbursement, bonus incentives, and career advancement opportunities.
- How does Ensemble Health Partners support professional development for this role?
- Ensemble Health Partners invests in professional development by offering paid certifications relevant to the associate's field and providing tuition reimbursement.