Senior auditor h1.location_city

Position Description:

The DRG Validation Auditor is a member of the CGI Healthcare Compliance, DRG Validation Team, with responsibility for reviewing medical records to determine the accuracy of coding and reimbursement for clinical services rendered to beneficiaries of health plans, including Commercial and Government Clients.

The DRG Validation Auditor is charged with rendering appropriate, well-supported, and thoroughly-documented decisions which may result in the identification of improper payments (overpayments and underpayments) on paid claims on behalf of the client from various providers of clinical services, including but not limited to acute care, long-term acute care, acute rehabilitation, and skilled nursing facilities, as well as other provider types and care settings.

The DRG Validation Auditor is prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in methods for review of the medical record and other provider documentation, application of appropriate coding guidelines, and use of the documentation format tailored to the client's requirements. Ongoing training and education are provided specific to audit processes, coding and reimbursement changes, and other topics as indicated.

The review process may result in changes to the payment for previously-rendered services, and decisions are rendered through a well-defined process which requires the Auditor to incorporate coding experience and knowledge, as well as critical thinking skills in order to assess available information and render a decision. The DRG Validation Auditor reports to a DRG Validation Team Leader, who provides support, feedback, and guidance to the Auditor. Audit performance review and quality assurance are provided through a well-defined review and quality management program.

Location: This position can be located remotely anywhere in the U.S.

Schedule: Candidates must be willing to work in Eastern Time Zone hours.

Your future duties and responsibilities:

Reviews inpatient medical records to validate assignment and sequencing of ICD-10 diagnosis and procedure codes, discharge status codes, Hospital Acquired Conditions (HACs), POA assignment, and DRG assignment.

Provides a detailed rationale for every medical record review resulting in a DRG Review Results letter, including supporting references.

Follows proper procedure for referral to Clinical Nurse Auditor or Physician Advisor, as applicable.

Utilizes proper reference material, standards, and guidelines for coding.

Provides input to the Edit Development team on claims selection criteria.

Verifies data received from client and work to resolve discrepancies.

If the contract requires onsite review, interacts with Providers and other personnel in a professional manner.

Follows CGI policies and processes, completing Red Carpet, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.

Communicates timely with Team Lead regarding illnesses, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.

Complies with department standards regarding productivity and audit quality.

Performs other duties as assigned.

Required qualifications to be successful in this role:

Credentials: The DRG Validation Auditor possesses current AHIMA credentials (RHIT/RHIA/CCS), with current CCS (certified coding specialist) preferred.

Experience: The Auditor demonstrates extensive knowledge of ICD-10-CM/PCS coding and DRG reimbursement, with a minimum of five years of inpatient coding experience. Previous experience training and mentoring junior-level coders is highly desired.

Methodology: The DRG Validation Auditor must understand government and commercial provider reimbursement methodologies (MS-DRG and APR-DRG), and possesses strong clinical validation skills, as well as data analytic skills.

Technical Skills: A working knowledge of computer functions and applications such as Microsoft Office (Outlook, Word, Excel) and Windows operating systems is required in order to manage applications utilized in the audit process.

Communication: The ability to write a well-reasoned review in a narrative style, with accurate spelling, grammar, punctuation, and sentence structure is required for success in the audit position.

Core Competencies: The auditor must be able to adapt to changing priorities in order to meet Client requirements, and is required to meet department productivity standards and deadlines.

Attributes: The auditor must be proactive and self-directed, self-sufficient in completing tasks, as well as detail-oriented, with a passion for life-long learning.

Travel: The Auditor may be required to travel for additional training and on-site reviews on an as-needed basis.



Other Information:

CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to skill set, level, experience, relevant training, and licensure and certifications. To support the ability to reward for merit-based performance, CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range for this role in the U.S. is $58,.00 - $,.00.
CGI's benefits are offered to eligible professionals on their first day of employment to include:
. Competitive compensation
. Comprehensive insurance options
. Matching contributions through the (k) plan and the share purchase plan
. Paid time off for vacation, holidays, and sick time
. Paid parental leave
.Learning opportunities and tuition assistance
. Wellness and Well-being programs