Univera Healthcare
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT,
Univera Healthcare, Buffalo, New York, United States, 14266
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)
The Payment Integrity DRG Coding & Clinical Validation Analyst position requires an extensive background in acute facility-based clinical documentation and/or inpatient coding, and a thorough understanding of the current MS‑DRG and APR‑DRG payment systems. The role is responsible for reviewing medical records to ensure appropriate provider documentation supports the principal diagnosis, comorbidities, complications, secondary diagnoses, surgical procedures, and POA indicators. The analyst validates coding and DRG assignment accuracy, ensuring physician documentation aligns with hospital coded data.
Essential Accountabilities Level I
Analyzes and audits acute inpatient claims, integrating medical chart coding principles, clinical guidelines, and objectivity in audit activities.
Applies advanced ICD‑10 coding expertise to substantiate conclusions.
Adheres to official coding guidelines, coding clinic determinations, CMS and regulatory compliance guidelines.
Establishes national and best‑practice benchmarks, measuring performance against them.
Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
Manages case volumes and audit schedules, prioritizing workload per management direction.
Demonstrates high standards of integrity, supporting the company’s mission and values.
Maintains respect for member privacy in accordance with corporate policies.
Maintains reliable attendance.
Performs additional functions as assigned by management.
Level II (in addition to Level I Accountabilities)
Performs complex audits or projects with minimal direction.
Acts as an expert in medical coding and record review, overseeing complex assignments and challenging stakeholders.
Supports leadership in projects related to departmental strategies and initiatives.
Participates in audits, payment methodologies, contractual agreements, and cross‑functional teams.
Mentors new hires.
Participates in internal/external committees.
Level III (in addition to Level II Accountabilities)
Provides expertise in developing audit data criteria.
Leads training, guidance, consultation, and complex performance analysis for team members.
Serves as an expert resource for escalations, working directly with Payment Integrity staff.
Provides backup support for management as necessary.
Minimum Qualifications Note: This role follows a differentiated classification approach, providing guidance for employee development and promotion opportunities.
All Levels
Associate or bachelor’s degree in health information management (RHIA or RHIT) or a Nursing Degree.
Three (3) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and knowledge of medical claims billing/pay‑ment systems.
Maintenance of a coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC).
Intermediate analytical and problem‑solving skills, and awareness 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 of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and extensive knowledge of billing systems.
Demonstrated ability across multiple skills, products, processes, and systems.
Ability to lead initiatives with occasional guidance from management.
Advanced analytical, problem‑solving, and judgement skills.
Advanced knowledge of PC, software, auditing tools and claims processing systems.
Level III (in addition to Level II Qualifications)
Eight (8) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and deep knowledge of billing systems.
Demonstrated leadership skills.
Subject‑matter expertise or consultative role in other departments.
Independent work with lead role in key business initiatives.
Expert proficiency in analytical skills, auditing, and management of complex assignments.
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 salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education, as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components may include group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
Please note: Remote work may be possible for all jobs posted by the Univara Healthcare Talent Acquisition team. This decision is made 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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Essential Accountabilities Level I
Analyzes and audits acute inpatient claims, integrating medical chart coding principles, clinical guidelines, and objectivity in audit activities.
Applies advanced ICD‑10 coding expertise to substantiate conclusions.
Adheres to official coding guidelines, coding clinic determinations, CMS and regulatory compliance guidelines.
Establishes national and best‑practice benchmarks, measuring performance against them.
Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
Manages case volumes and audit schedules, prioritizing workload per management direction.
Demonstrates high standards of integrity, supporting the company’s mission and values.
Maintains respect for member privacy in accordance with corporate policies.
Maintains reliable attendance.
Performs additional functions as assigned by management.
Level II (in addition to Level I Accountabilities)
Performs complex audits or projects with minimal direction.
Acts as an expert in medical coding and record review, overseeing complex assignments and challenging stakeholders.
Supports leadership in projects related to departmental strategies and initiatives.
Participates in audits, payment methodologies, contractual agreements, and cross‑functional teams.
Mentors new hires.
Participates in internal/external committees.
Level III (in addition to Level II Accountabilities)
Provides expertise in developing audit data criteria.
Leads training, guidance, consultation, and complex performance analysis for team members.
Serves as an expert resource for escalations, working directly with Payment Integrity staff.
Provides backup support for management as necessary.
Minimum Qualifications Note: This role follows a differentiated classification approach, providing guidance for employee development and promotion opportunities.
All Levels
Associate or bachelor’s degree in health information management (RHIA or RHIT) or a Nursing Degree.
Three (3) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and knowledge of medical claims billing/pay‑ment systems.
Maintenance of a coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC).
Intermediate analytical and problem‑solving skills, and awareness 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 of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and extensive knowledge of billing systems.
Demonstrated ability across multiple skills, products, processes, and systems.
Ability to lead initiatives with occasional guidance from management.
Advanced analytical, problem‑solving, and judgement skills.
Advanced knowledge of PC, software, auditing tools and claims processing systems.
Level III (in addition to Level II Qualifications)
Eight (8) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and deep knowledge of billing systems.
Demonstrated leadership skills.
Subject‑matter expertise or consultative role in other departments.
Independent work with lead role in key business initiatives.
Expert proficiency in analytical skills, auditing, and management of complex assignments.
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 salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education, as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components may include group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
Please note: Remote work may be possible for all jobs posted by the Univara Healthcare Talent Acquisition team. This decision is made on a case‑by‑case basis.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Accounting/Auditing and Finance
Industries Insurance
#J-18808-Ljbffr