Excellus BCBS
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT,
Excellus BCBS, Elmira, New York, United States
Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)
Employer:
Excellus BCBS
Summary:
The Payment Integrity DRG Coding & Clinical Validation Analyst role focuses on reviewing acute facility‑based clinical documentation and inpatient claims to ensure accurate DRG and ICD‑10 coding, compliance with MS‑DRG and APR‑DRG payment systems, and adherence to coding guidelines. The analyst validates coding and DRG assignment against medical records, diagnoses, comorbidities, complications, procedures, and POA indicators to support accurate hospital coded data.
Essential Accountabilities – Level I
Analyzes and audits acute inpatient claims, applying medical chart coding principles, clinical guidelines, and objectivity.
Applies advanced ICD‑10 coding expertise and DRG grouping to support accurate payment.
Adheres to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines.
Establishes national best‑practice benchmarks and measures performance against benchmarks.
Manages case volumes and review/audit schedules with priority based on management assignment.
Demonstrates high standards of integrity, supporting the Lifetime Healthcare Companies’ mission and values.
Maintains privacy of member data in accordance with corporate privacy policies.
Ensures consistent attendance and performs other functions as assigned.
Essential Accountabilities – Level II
Performs complex audits or projects with minimal direction.
Acts as an expert in medical coding and record review, overseeing complex assignments and challenging customers.
Supports leadership in departmental initiatives and cross‑functional projects.
Represents the team in audits, payment methodologies, and contractual agreements.
Mentors new hires and participates in internal/external committees.
Essential Accountabilities – Level III
Develops data criteria for audits and provides expert guidance to team members.
Leads complex performance analysis, coaching, and continuous quality improvement initiatives.
Serves as a resource for escalations and works with Payment Integrity staff to resolve issues.
Provides backup support for management as needed.
Minimum Qualifications – All Levels
Associate or bachelor’s degree in health information management (RHIA or RHIT) or nursing.
Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding in an acute facility setting.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
RHIA or RHIT, or CCS or CIC inpatient coding credential.
Intermediate analytical and problem‑solving skills.
Intermediate knowledge of PC, software, auditing tools and claims processing systems.
Minimum Qualifications – Level II
Five (5) years’ 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.
Demonstrated leadership across multiple systems.
Advanced analytical, problem‑solving, and judgement skills.
Advanced knowledge of PC, software, auditing tools and claims processing systems.
Minimum Qualifications – Level III
Eight (8) years’ 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.
Demonstrated leadership and subject‑matter expertise.
Expert proficiency in auditing skillset and complex assignment management.
Expert proficiency in project management and presentation skills.
Physical Requirements
Ability to work prolonged periods sitting or standing at a workstation and using a computer.
Ability to travel within the health plan service region for meetings and training as needed.
Compensation Range(s): Level I: Grade E4 – $65,346 to $117,622 Level II: Grade E5 – $71,880 to $129,384 Level III: Grade E6 – $79,068 to $142,322
Salary ranges represent the minimum and maximum for this position. Actual pay will vary based on budget, experience, and internal equity. The full rewards package includes group health and dental insurance, retirement plan, wellness program, paid time off, and paid holidays.
Remote: There may be opportunities for remote work within all Excellus Talent Acquisition postings, reviewed on a case‑by‑case basis.
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 veteran status.
Job Details
Seniority level:
Mid‑Senior level
Employment type:
Full‑time
Job function:
Accounting/Auditing and Finance
Industries:
Insurance
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Excellus BCBS
Summary:
The Payment Integrity DRG Coding & Clinical Validation Analyst role focuses on reviewing acute facility‑based clinical documentation and inpatient claims to ensure accurate DRG and ICD‑10 coding, compliance with MS‑DRG and APR‑DRG payment systems, and adherence to coding guidelines. The analyst validates coding and DRG assignment against medical records, diagnoses, comorbidities, complications, procedures, and POA indicators to support accurate hospital coded data.
Essential Accountabilities – Level I
Analyzes and audits acute inpatient claims, applying medical chart coding principles, clinical guidelines, and objectivity.
Applies advanced ICD‑10 coding expertise and DRG grouping to support accurate payment.
Adheres to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines.
Establishes national best‑practice benchmarks and measures performance against benchmarks.
Manages case volumes and review/audit schedules with priority based on management assignment.
Demonstrates high standards of integrity, supporting the Lifetime Healthcare Companies’ mission and values.
Maintains privacy of member data in accordance with corporate privacy policies.
Ensures consistent attendance and performs other functions as assigned.
Essential Accountabilities – Level II
Performs complex audits or projects with minimal direction.
Acts as an expert in medical coding and record review, overseeing complex assignments and challenging customers.
Supports leadership in departmental initiatives and cross‑functional projects.
Represents the team in audits, payment methodologies, and contractual agreements.
Mentors new hires and participates in internal/external committees.
Essential Accountabilities – Level III
Develops data criteria for audits and provides expert guidance to team members.
Leads complex performance analysis, coaching, and continuous quality improvement initiatives.
Serves as a resource for escalations and works with Payment Integrity staff to resolve issues.
Provides backup support for management as needed.
Minimum Qualifications – All Levels
Associate or bachelor’s degree in health information management (RHIA or RHIT) or nursing.
Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding in an acute facility setting.
Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG.
RHIA or RHIT, or CCS or CIC inpatient coding credential.
Intermediate analytical and problem‑solving skills.
Intermediate knowledge of PC, software, auditing tools and claims processing systems.
Minimum Qualifications – Level II
Five (5) years’ 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.
Demonstrated leadership across multiple systems.
Advanced analytical, problem‑solving, and judgement skills.
Advanced knowledge of PC, software, auditing tools and claims processing systems.
Minimum Qualifications – Level III
Eight (8) years’ 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.
Demonstrated leadership and subject‑matter expertise.
Expert proficiency in auditing skillset and complex assignment management.
Expert proficiency in project management and presentation skills.
Physical Requirements
Ability to work prolonged periods sitting or standing at a workstation and using a computer.
Ability to travel within the health plan service region for meetings and training as needed.
Compensation Range(s): Level I: Grade E4 – $65,346 to $117,622 Level II: Grade E5 – $71,880 to $129,384 Level III: Grade E6 – $79,068 to $142,322
Salary ranges represent the minimum and maximum for this position. Actual pay will vary based on budget, experience, and internal equity. The full rewards package includes group health and dental insurance, retirement plan, wellness program, paid time off, and paid holidays.
Remote: There may be opportunities for remote work within all Excellus Talent Acquisition postings, reviewed on a case‑by‑case basis.
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 veteran status.
Job Details
Seniority level:
Mid‑Senior level
Employment type:
Full‑time
Job function:
Accounting/Auditing and Finance
Industries:
Insurance
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