Auditor III - DRG

EXL is hiring a DRG Auditor III. This is a remote, work from home opportunity.

Summary: 

In this fully remote position as a DRG Auditor you will apply your expert knowledge of DRG coding and reimbursement, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient medical records to validate or revise the provider's billed DRG code. You will utilize industry and EXL proprietary tools in the DRG assignment process, and will write professional communications documenting audit findings and supporting rationales. You will also apply your extensive coding and industry knowledge to identify audit trends and identify referrals for Clinical Validation review.

Responsibilities:

• Conduct MS-DRG and/or APR-DRG coding reviews to verify the accuracy of the DRG assignment and reimbursement.
• Apply coding guidelines to a variety of claim scenarios and effectively utilize industry and proprietary tools to maximize overpayment identifications.
• Document audit results in a clear, concise, and effective manner using AHA Coding Clinic Guidelines and ICD 10 CM/PCS coding rules and guidelines.
• Utilize proprietary workflow systems and encoder tools (e.g., 3M, Webstrat, etc.) efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly.
• Meet or exceed EXL established program productivity and quality goals, including uphold rate for appeals.
• Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements.
• Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.

Qualifications:

• Minimum High School Diploma
• One or more of the following credentials: CCS, RHIA, RHIT; preference given to those with multiple credentials
• 4+ years of MS DRG/APR DRG coding experience with expert knowledge of AHA Coding Guidelines, DRG reimbursement methodologies, and familiarity with healthcare payer contract language.
• Prefer candidate with prior DRG retrospective overpayment identification auditing experience.

Knowledge, Skills, Behaviors:

• Expert Inpatient Coding Skills. Superior knowledge of regulatory ICD-10-CM/PCS coding, Official Guidelines for Coding and Reporting and Coding Clinic Guidance coupled with MS-DRG and APR-DRG payment methodologies including Hospital Acquired Conditions (HACs), POA assignment, and Discharge Disposition codes.
• Experience with DRG encoder tools (3M, Webstrat).
• Works independently in a remote environment and delivers exceptional results during EXL core business hours.
• Possesses excellent time management and work prioritization skills.
• Takes ownership of problem solving.