Nurse Coder DRG Auditor III

Job Description

TREND Health Partners is a tech-enabled payment integrity company. Our mission is to facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving access to healthcare. We achieve this by aligning the common goals of payers and providers and fostering collaboration through a shared technology platform and seamless workflows.

Joining TREND Health Partners means becoming part of a dynamic, growing organization that promotes a collaborative and innovative work environment.

The Nurse Coder DRG Auditor III’s primary responsibility is to operate as a Subject Matter Expert. Independently audit outpatient and inpatient claims applying coding guidelines while reviewing supporting medical documentation, completing appeal responses and communicating findings;Independently validate and perform quality checks for other team members;Execute strategic decision making authority, and support management with enterprise level recommendations.

Role and Responsibilities

• Utilize coding guidelines and clinical guidelines to perform DRG or APC validation
• Validate principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses and procedures utilizing the medical record
• Evaluate short stay claims for medical necessity of an inpatient level of care
• Apply CPT and ICD-10 guidelines
• Apply policies, procedures, guidelines and regulations developed by Centers for Medicare and Medicaid Services (CMS), commercial payers, InterQual, MCG, and Trend Health Partners
• Provide appeal responses for claims of the above types utilizing industry standards and company/client policies
• Assist with new concept development
• Assist with claim selection criteria
• Assist with itemized bill review as needed
• Maintain licensures, certifications and continuing education requirements
• May require client communication to support findings
• Independently apply and establish guidelines for others to apply coding guidelines
• Performs quality checks for other team members

Qualifications

• An active RN professional license in good standing
• Clinical practice experience
• Coding certification in good standing. Examples: CCS, CIC
• Coding validation/auditing experience
• Well-developed verbal and written communication skills coupled with recognizable organization
• Ability to effectively prioritize tasks
• Microsoft Office experience, specifically Excel

Preferred Skills

• Appeals experience a plus
• APR-DRG experience a plus
• Client communication experience a plus
• Concept development experience a plus
• Claim selection experience a plus
• Experience with machine learning/artificial intelligence a plus
• Case Management and/or Utilization Review experience a plus
• Clinical Documentation Improvement experience a plus
• Itemized bill validation experience a plus
• Quality Assurance experience a plus
• Management experience a plus
• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) a plus
• TruCode/TruBridge, 3M, WebStrat or similar experience a plus

Mental and Physical Demands

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
• The nature of the work is sedentary, and the employee will be sitting most of the time.
• Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.
• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

Related duties as assigned

• This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.
• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.