Nurse Coder DRG Auditor I

At Trend Health Partners, 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 a part of a dynamic growing organization that promotes a collaborative and innovative work environment. Our comprehensive compensation package includes competitive salaries, highly valued health insurance, a 401(k) plan with employer match, paid parental leave, and more.

The Nurse Coder DRG Auditor’s primary responsibility is to review medical records and associated claim information to validate accuracy of DRG assignments, APC assignments and/or medical necessity for inpatient level of care. This role will apply coding and clinical principles based on industry standards and company/client guidelines.

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

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