Clinical Review QC Auditor
美国特克西州福特沃斯市的 Ceris 正在寻求一个 DRG 质量控制/临床审计员。诊断相关组 (DRG) 的临床审核员将负责对医疗记录和/或其他文档进行 DRG 验证 （临床/编码）审查。该角色将确定正确的 DRG/编码，根据评估类型特定的检查方法定义。这包括完成医学记录审查，准确地记录发现和非发现以及为确定提供临床/政策/监管支持。这一职位将利用他们与 ICD-10-CM&PCS 编码指南的经验，了解现代药学，疾病管理和临床干预程序的能力。理想的 DRG 临床审计员候选人具有强大的书面和口头沟通技能，对疾病过程的临床知识以及医疗必要性规则的知识。这是一个远程职位。关键功能和责任：·通过编码检查和支持临床文档审查来确定账单准确性的医学记录；· 进行审计以确保准确的退款和确定潜在节省 ·审查先前进行的审计以保证准确编码和识别潜在节约 · 对客户发送的所有机会进行完整和正确信息 · 证明对 ICD-10-CM 代码，PCS 和 DRG 代码的知识，了解纳税人规则和规定，包括医疗保险和医疗补助 ·理解并遵守所有内部和外部政策 · 实操了解 HIPAA 隐私与安全规则 ·协助质量控制团队和医学总监提出上诉，反驳等。·及时通知领导层任何问题或关切。· 赋予的额外职责：· 对现行官方编码指南和编码诊所引用的专家知识 · 成功证明代码任务使用的临床标准文件要求的坚实的认识和理解 · 熟练了解医疗保险，CMS 指导方针和 ICD-10编码指导方程 · 语言和书面有效和专业沟通技能 · 在团队环境中独立工作的能力 ·高度关注细节 ·必须具备批判性思维能力 · 多任务并协助团队覆盖和提供支持时的能力
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CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules.
This is a remote position.
ESSENTIAL FUNCTIONS & RESPONSIBILITIES:
- Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
- Check for physician's notes supporting the DRGs assigned
- Conduct audits to ensure accurate reimbursement and identifying potential savings
- Review previously conducted audits to ensure accurate coding and identifying potential savings
- Review all opportunities sent to the customers for complete and correct information
- Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid
- Understand and comply with all internal and external policies
- Working knowledge of HIPAA Privacy and Security Rules
- Assist Quality Control team and medical director with appeals, rebuttals, etc.
- Notify leadership of any issues or concerns in a timely manner
- Additional duties as assigned
KNOWLEDGE & SKILLS:
- Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations
- Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments
- Proficient understanding of Medicare, CMS guidelines and ICD-10 coding guidelines
- Effective and professional communication skills, both verbal and written
- Ability to work independently and in a team environment
- High attention to detail
- Must possess critical thinking skills
- Ability to multi-task and assist with team coverage and provide support when needed
- Ability to build relationships both internally and externally
- Ability to work in a fast-paced environment
- Demonstrated proficiency in basic computer skills and typing
- Proficiency with Microsoft Office
- Proficient in both MS and APR DRG methodology preferred
EDUCATION & EXPERIENCE:
- LVN or RN license in the state of employment preferred
- Experience in the OR, ICU, or ER as an RN highly preferred
- Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan. National Coding Certification required through either AHIMA (preferred) or AAPC
- Extensive hands-on ICD-10 CM / PCS experience required
PAY RANGE:
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.
For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.
Pay Range: $68,566 – $104,841
A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management
In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.
ABOUT CERIS:
CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
Originally posted on Himalayas