Excellus BCBS
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT,
Excellus BCBS, Latham, New York, United States
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)
Job Description:
The Payment Integrity DRG Coding & Clinical Validation Analyst position requires extensive background in acute facility‑based clinical documentation and inpatient coding with a high level of understanding of current MS‑DRG, APR‑DRG payment systems. This role is responsible for reviewing medical records for appropriate provider documentation to support principal diagnosis, co‑merbidities, complications, secondary diagnosis, surgical procedures, and POA indicators to validate coding and DRG assignment accuracy, ensuring physician documentation supports the hospital coded data.
Essential Accountabilities
Level I
Analyze and audit acute inpatient claims. Integrate medical chart coding principles, clinical guidelines, and objectivity in medical audit activities.
Apply advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Perform work independently.
Adhere to official coding guidelines, coding clinic determinations, CMS and other regulatory compliance guidelines and mandates.
Establish national and best‑practice benchmarks and measure performance against benchmarks.
Ensure accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
Manage case volumes and review/audit schedules, prioritizing case load as assigned by management.
Demonstrate integrity, uphold company mission and values, and adhere to privacy policies.
Maintain reliable attendance.
Perform other functions as assigned.
Level II (in addition to Level I Accountabilities)
Perform complex audits or projects with minimal direction.
Act as an expert in reviewing medical coding and medical record review, oversee complex assignments, and handle challenging customers.
Support leadership in projects related to divisional strategies and initiatives.
Participate in audits, payment methodologies, contractual agreements, and cross‑functional teams.
Serve as a mentor to new hires.
Represent department on internal/external committees.
Level III (in addition to Level II Accountabilities)
Provide expertise in developing data criteria for audits.
Act as a lead and provide training, guidance, and coaching on continuous quality improvement methods.
Serve as an expert and resource for escalations, working directly with Payment Integrity staff to resolve issues.
Provide backup support for management as needed.
Minimum Qualifications NOTE: Multiple levels of classification differentiate demonstrated knowledge, skills, and independence. All levels and higher qualifications:
Associate or bachelor’s degree in health information management (RHIA or RHIT) or a nursing degree.
Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG with broad knowledge of medical claims billing/payment systems and coding terminology.
Coding certification condition of employment: RHIA or RHIT, inpatient coding credential – CCS or CIC.
Intermediate analytical and problem‑solving skills and up‑to‑date knowledge of business analysis trends.
Intermediate knowledge of PC software, auditing tools, and claims processing systems.
Level II (in addition to Level I Qualifications)
Five (5) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
Demonstrated ability across multiple skills, products, processes, and systems with the division.
Lead initiatives with occasional guidance from management.
Advanced analytical, problem‑solving, and judgment skills.
Advanced knowledge of PC software, auditing tools, and claims processing systems.
Level III (in addition to Level II Qualifications)
Eight (8) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
Demonstrated leadership skills.
Subject‑matter expertise or consultant role to other departments.
Independent work and lead key business initiatives.
Expert proficiency in analytical, auditing skillset, managing complex assignments, and handling highly visible issues.
Expert proficiency in project management and presentation skills.
Physical Requirements
Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
Ability to travel across the health plan service region for meetings and/or trainings as needed.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Compensation Range(s) Level I: Grade E4 – Minimum $65,346, Maximum $117,622.
Level II: Grade E5 – Minimum $71,880, Maximum $129,384.
Level III: Grade E6 – Minimum $79,068, Maximum $142,322.
The posted salary range reflects the minimum and maximum for this position. Actual salary may vary based on experience, knowledge, skill, and education. Total rewards package may include health/dental insurance, retirement plan, wellness program, paid time off, and holidays.
Note: Remote work opportunity may be considered on a case‑by‑case basis.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Accounting/Auditing and Finance
Industries: Insurance
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The Payment Integrity DRG Coding & Clinical Validation Analyst position requires extensive background in acute facility‑based clinical documentation and inpatient coding with a high level of understanding of current MS‑DRG, APR‑DRG payment systems. This role is responsible for reviewing medical records for appropriate provider documentation to support principal diagnosis, co‑merbidities, complications, secondary diagnosis, surgical procedures, and POA indicators to validate coding and DRG assignment accuracy, ensuring physician documentation supports the hospital coded data.
Essential Accountabilities
Level I
Analyze and audit acute inpatient claims. Integrate medical chart coding principles, clinical guidelines, and objectivity in medical audit activities.
Apply advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Perform work independently.
Adhere to official coding guidelines, coding clinic determinations, CMS and other regulatory compliance guidelines and mandates.
Establish national and best‑practice benchmarks and measure performance against benchmarks.
Ensure accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
Manage case volumes and review/audit schedules, prioritizing case load as assigned by management.
Demonstrate integrity, uphold company mission and values, and adhere to privacy policies.
Maintain reliable attendance.
Perform other functions as assigned.
Level II (in addition to Level I Accountabilities)
Perform complex audits or projects with minimal direction.
Act as an expert in reviewing medical coding and medical record review, oversee complex assignments, and handle challenging customers.
Support leadership in projects related to divisional strategies and initiatives.
Participate in audits, payment methodologies, contractual agreements, and cross‑functional teams.
Serve as a mentor to new hires.
Represent department on internal/external committees.
Level III (in addition to Level II Accountabilities)
Provide expertise in developing data criteria for audits.
Act as a lead and provide training, guidance, and coaching on continuous quality improvement methods.
Serve as an expert and resource for escalations, working directly with Payment Integrity staff to resolve issues.
Provide backup support for management as needed.
Minimum Qualifications NOTE: Multiple levels of classification differentiate demonstrated knowledge, skills, and independence. All levels and higher qualifications:
Associate or bachelor’s degree in health information management (RHIA or RHIT) or a nursing degree.
Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG with broad knowledge of medical claims billing/payment systems and coding terminology.
Coding certification condition of employment: RHIA or RHIT, inpatient coding credential – CCS or CIC.
Intermediate analytical and problem‑solving skills and up‑to‑date knowledge of business analysis trends.
Intermediate knowledge of PC software, auditing tools, and claims processing systems.
Level II (in addition to Level I Qualifications)
Five (5) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
Demonstrated ability across multiple skills, products, processes, and systems with the division.
Lead initiatives with occasional guidance from management.
Advanced analytical, problem‑solving, and judgment skills.
Advanced knowledge of PC software, auditing tools, and claims processing systems.
Level III (in addition to Level II Qualifications)
Eight (8) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding for hospital or acute facility setting.
Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
Demonstrated leadership skills.
Subject‑matter expertise or consultant role to other departments.
Independent work and lead key business initiatives.
Expert proficiency in analytical, auditing skillset, managing complex assignments, and handling highly visible issues.
Expert proficiency in project management and presentation skills.
Physical Requirements
Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
Ability to travel across the health plan service region for meetings and/or trainings as needed.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Compensation Range(s) Level I: Grade E4 – Minimum $65,346, Maximum $117,622.
Level II: Grade E5 – Minimum $71,880, Maximum $129,384.
Level III: Grade E6 – Minimum $79,068, Maximum $142,322.
The posted salary range reflects the minimum and maximum for this position. Actual salary may vary based on experience, knowledge, skill, and education. Total rewards package may include health/dental insurance, retirement plan, wellness program, paid time off, and holidays.
Note: Remote work opportunity may be considered on a case‑by‑case basis.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Accounting/Auditing and Finance
Industries: Insurance
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