Conifer Health Solutions
DRG Coding Auditor - CDI Remote - $10K Sign On Bonus
Conifer Health Solutions, Frisco, Texas, United States, 75034
Overview
DRG Coding Auditor - CDI Remote - $10K Sign On Bonus at Conifer Health Solutions. Job Summary
The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims are coded and billed in accordance with nationally recognized coding guidelines, standards, regulations, and regulatory requirements, as well as payor and billing guidelines. The responses may include system documentation of findings and/or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership, and Conifer Compliance as warranted. The Auditor will perform analysis on clinical documentation, evidence-based criteria, physician documentation, physician advisor input, and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to CRC leadership. Provides expert application of evidence-based medical necessity review criteria tools and collaborates to review, evaluate, and improve the denial appeal process. Essential Duties and Responsibilities
Formulates and submits letters of appeal. Creates effective appeals utilizing relevant clinical documentation from the medical record, supported by current industry clinical guidelines, coding guidelines, evidence-based medicine, and appropriate standards and protocols. Performs reviews of accounts denied for DRG validation and DRG downgrades. Documents in the denial tracking tool (e.g., ACE). Maintains and distributes reports as needed to leadership. Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRGs, Outlier Payments, and Stop Loss calculations. Collaborates with Physician Advisors and CRC leadership on documentation-specific areas of concern. Maintains expertise in clinical areas and current trends in healthcare, inpatient coding, reimbursement methodologies, and utilization management. Knowledge, Skills, Abilities
Organizes work priorities and demonstrates compliance with departmental safety and security policies. Exhibits critical thinking, analytical skills, and problem resolution abilities. Ability to handle multiple assignments independently with minimal supervision. Maintains accuracy while meeting unit KPI goals. Excellent written and verbal communication skills; detail-oriented and able to work independently and in a team. Moderate skills in MS Excel, PowerPoint, and MS Office. Ability to research difficult coding and documentation issues and follow through to resolution. Ability to work in a virtual setting under minimal supervision. Ability to research state/federal guidelines and regulatory guidelines related to government audit processes. Education / Experience
Education
Minimum Required: Completion of BSN Degree Program or three years of RN experience with BSN to be completed within five years of employment; RN license in the state of practice; current knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. Preferred/Desired: BSN (preferred); CCDS or inpatient coding certification. Experience
Minimum Required: Three to five years of clinical RN experience; three to five years of Clinical Documentation Integrity experience; expertise with InterQual and/or MCG Disease Management; strong communication skills; knowledge of CMS regulations and inpatient coding guidelines; 1-2 years of current experience with reimbursement methodologies. Preferred/Desired: Experience preparing appeals for clinical denials related to DRG assignment; strong understanding of coding and billing guidelines (e.g., CMS, AHA Coding Clinics, AAMAS, state regulations). Certifications, Licenses, Registrations
Required: RN license; CCDS or related clinical documentation specialist certification, and/or AHIMA or AAPC coding credentials (CCS, CCA, CIC, CPC, CPMA). Preferred: BSN. Physical Demands
The physical demands described here are representative of those that must be met by an employee to perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to lift 15-30 lbs Ability to travel approximately 10% of the time to client sites or other designated sites Ability to sit and work at a computer for prolonged periods performing medical record quality reviews Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Typical office environment with desk, chair, and standard office equipment Other
Interaction with facility HIM and/or physician advisors Must meet the requirements of the Conifer Telecommuting Policy and Procedure Compensation and Benefits
Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience. Management-level positions may be eligible for sign-on and relocation bonuses. Benefits include medical, dental, vision, disability, life, business travel insurance; paid time off; 401k with up to 6% employer match; 10 paid holidays; health savings accounts and dependent flexible spending accounts; Employee Assistance program and discounts; voluntary benefits; Colorado-specific paid leave where applicable. EEO statement: Employment practices will not be influenced by race, color, religion, sex, national origin, age, disability, or other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would cause undue hardship. Job Details
Seniority level: Associate Employment type: Full-time Job function: Accounting/Auditing and Finance Industries: Hospitals and Health Care and Medical Practices
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DRG Coding Auditor - CDI Remote - $10K Sign On Bonus at Conifer Health Solutions. Job Summary
The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims are coded and billed in accordance with nationally recognized coding guidelines, standards, regulations, and regulatory requirements, as well as payor and billing guidelines. The responses may include system documentation of findings and/or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership, and Conifer Compliance as warranted. The Auditor will perform analysis on clinical documentation, evidence-based criteria, physician documentation, physician advisor input, and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to CRC leadership. Provides expert application of evidence-based medical necessity review criteria tools and collaborates to review, evaluate, and improve the denial appeal process. Essential Duties and Responsibilities
Formulates and submits letters of appeal. Creates effective appeals utilizing relevant clinical documentation from the medical record, supported by current industry clinical guidelines, coding guidelines, evidence-based medicine, and appropriate standards and protocols. Performs reviews of accounts denied for DRG validation and DRG downgrades. Documents in the denial tracking tool (e.g., ACE). Maintains and distributes reports as needed to leadership. Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRGs, Outlier Payments, and Stop Loss calculations. Collaborates with Physician Advisors and CRC leadership on documentation-specific areas of concern. Maintains expertise in clinical areas and current trends in healthcare, inpatient coding, reimbursement methodologies, and utilization management. Knowledge, Skills, Abilities
Organizes work priorities and demonstrates compliance with departmental safety and security policies. Exhibits critical thinking, analytical skills, and problem resolution abilities. Ability to handle multiple assignments independently with minimal supervision. Maintains accuracy while meeting unit KPI goals. Excellent written and verbal communication skills; detail-oriented and able to work independently and in a team. Moderate skills in MS Excel, PowerPoint, and MS Office. Ability to research difficult coding and documentation issues and follow through to resolution. Ability to work in a virtual setting under minimal supervision. Ability to research state/federal guidelines and regulatory guidelines related to government audit processes. Education / Experience
Education
Minimum Required: Completion of BSN Degree Program or three years of RN experience with BSN to be completed within five years of employment; RN license in the state of practice; current knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. Preferred/Desired: BSN (preferred); CCDS or inpatient coding certification. Experience
Minimum Required: Three to five years of clinical RN experience; three to five years of Clinical Documentation Integrity experience; expertise with InterQual and/or MCG Disease Management; strong communication skills; knowledge of CMS regulations and inpatient coding guidelines; 1-2 years of current experience with reimbursement methodologies. Preferred/Desired: Experience preparing appeals for clinical denials related to DRG assignment; strong understanding of coding and billing guidelines (e.g., CMS, AHA Coding Clinics, AAMAS, state regulations). Certifications, Licenses, Registrations
Required: RN license; CCDS or related clinical documentation specialist certification, and/or AHIMA or AAPC coding credentials (CCS, CCA, CIC, CPC, CPMA). Preferred: BSN. Physical Demands
The physical demands described here are representative of those that must be met by an employee to perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to lift 15-30 lbs Ability to travel approximately 10% of the time to client sites or other designated sites Ability to sit and work at a computer for prolonged periods performing medical record quality reviews Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Typical office environment with desk, chair, and standard office equipment Other
Interaction with facility HIM and/or physician advisors Must meet the requirements of the Conifer Telecommuting Policy and Procedure Compensation and Benefits
Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience. Management-level positions may be eligible for sign-on and relocation bonuses. Benefits include medical, dental, vision, disability, life, business travel insurance; paid time off; 401k with up to 6% employer match; 10 paid holidays; health savings accounts and dependent flexible spending accounts; Employee Assistance program and discounts; voluntary benefits; Colorado-specific paid leave where applicable. EEO statement: Employment practices will not be influenced by race, color, religion, sex, national origin, age, disability, or other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would cause undue hardship. Job Details
Seniority level: Associate Employment type: Full-time Job function: Accounting/Auditing and Finance Industries: Hospitals and Health Care and Medical Practices
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