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DRG Coding Auditor Principal

Company: Anthem, Inc
Location: West Covina
Posted on: June 23, 2022

Job Description:

Description SHIFT: Day JobSCHEDULE: Full-time Be part of an extraordinary team We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and evolving, high-performance culture that empowers you to make an impact? Responsible for auditing inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology, including case rate and per diem, generating highly complex audit findings recoverable claims for the benefit of the Company, for all lines of business, and its clients. Specializes in review of DRG coding via medical record and attending physician's statement provided by acute care hospitals on paid DRG, especially on very complex coding cases that are paid using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methodology and findings may be so complex and advanced that disputes or appeals may only be reviewed by other DRG Coding Audit Principals (or Executives).Primary duties may include, but are not limited to:+ Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices), complex clinical guidelines and maintaining objectivity in the performance of medical audit activities.+ Draws on extremely advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.+ Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.+ Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower level auditors.+ Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs) or Never Events.+ Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.+ Operates largely independently and autonomously with little oversight due to extremely high quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.+ Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge.+ Collaborates with management to improve selection criteria. Qualifications Requires at least one of the following: AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing. Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder. Requires minimum of 10 years experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG. BA/BS preferred. Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred. Broad, deep and niche knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology strongly preferred. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Anthem approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World's Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance. REQNUMBER: PS74713

Keywords: Anthem, Inc, West Covina , DRG Coding Auditor Principal, Accounting, Auditing , West Covina, California

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