DRG Reviewer (Onsite)

Who We Are

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 60 health plans, including many of the top 20, and representing more than 160 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Location: This role is onsite in Nashville, TN

About the Opportunity

The Onsite DRG Reviewer is responsible for providing MS-DRG and APR-DRG audits services at provider locations on behalf of our clients This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. The DRG Reviewer examines medical records to validate accuracy of the UB and items billed for accurate DRG assignment along with appropriate customer payment policies applied to each case reviewed. The DRG Reviewer must be able to work independently with minimal supervision. Strong customer service skills are required. This position is an onsite audit position that requires the DRG Reviewer to live in the commutable vicinity of Nashville, TN and be able to go onsite daily to the facilities as scheduled.

What You'll Do

• Claims Review: Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.
• Written Communication: Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.
• Collaboration: Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.
• Coding Knowledge: Maintains expert knowledge of ICD-10-CM/PCS coding conventions and rules, Official Coding Guidelines and American Hospital Association (AHA) Coding Clinic.
• Quality and Time Management: Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team, meets productivity requirements
• Technically savvy: Ability to use multiple tools, provider systems, and different medical records systems to perform audits in a comprehensive and timely manner
• Proficiency: Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and rationales
• HIPAA Compliance: Assures HIPAA compliance for protected health information.
• Presentation skills: Participates in exit interviews with the client summarizing audit findings, which can vary depending on client/ facility
• Practice Standards: Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Other duties as assigned.

General

• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS).
• Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years' experience performing DRG validation.
• Previous auditing/ recovery experience preferred.
• Excellent oral and written communication skills.
• Comprehensive knowledge of the DRG structure and regulatory requirements

Education (required)

• Associate or bachelor's degree in nursing (active/unrestricted license); or
• Associate or bachelor's degree in health information management; or
• Work experience may be considered in lieu of formal education at leadership discretion

Certification (at least one of the following is required)

• RHIA - Registered Health Information Administrator; or
• RHIT- Registered Health Information Technician; or
• CCDS - Certified Clinical Documentation Specialist; or
• CDIP - Clinical Documentation Improvement Practitioner; or
• CCS - Certified Coding Specialist; or
• CPC-H, Certified Professional Coder-H (Hospital Based); or
• CIC, Certified Inpatient Coder

Experience

• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required
• Inpatient Clinical Documentation Integrity experience of 2 years or more required
• Exhibits high standards for quality and attention to detail
• Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
• Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations
• Solid knowledge and understanding of clinical criteria and documentation requirements to successfully substantiate code assignments
• Subject matter expert in DRG methodologies (e.g., MS & APR)
• Subject matter expert in ICD-10-CM/PCS coding methodologies, UHDDS definitions, Official Coding Guidelines and AHA's Coding Clinic Guidelines
• Demonstrates ability to work efficiently and effectively with minimal direct supervision

Computer Equipment and Software

• Experience working with laptops and multiple monitors
• Experience working remotely
• Working knowledge of Windows office systems including full Microsoft Suite and Teams
• Experience with various forms of software and experience engaging development teams
• Experience with Encoder/Grouper programs (TruCode/3M) and/or similar coding and auditing tools

Physical Demands

• Requires the ability to sit or stand for long periods of time, occasional stooping, and reaching; May require lifting up to 25 pounds; Requires a normal range of vision and hearing with or without accommodations; Position is not substantially exposed to adverse environmental conditions
• Requires ability to travel to multiple locations, as scheduled, within the commutable vicinity of residence.

Pay range: $90,000-$110,000

This is an exempt position. The salary range is for Base Salary.Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS). Highly recommend ICD-10 specialized training.
• Comprehensive knowledge of the DRG structure and other health care payment methodologies and regulatory requirements.
• Minimum of five to seven years hospital inpatient coding for PPS reimbursement or at least 2 years experience performing DRG validation.
• Proven self-direction in the planning and execution of DRG validation and recovery functions.
• Demonstrated exemplary professional coding judgment.
• Confirmed effective communication in staff supervision and teaching.
• Proven operations analysis, including productivity and financial skills.
• Ability to adhere to the highest ethical standards including honesty, integrity, dedication and leadership.
• Demonstrated ability to gain support for ideas and lead others to accomplish objectives.
• Demonstrated success rate in selection of cases that result in overpayment/recovery
• Organization, flexibility and multiple task/project orientation to handle duties assigned.
• Skill in focusing on desired results, determining what is important and urgent, clarifying next steps, and delegating effectively to meet deadlines and achieve desired results.
• Must possess excellent oral, written and presentation skills.
• Demonstrated proficiency in multiple computer applications (MS Office), DRG Grouper/Pricer software, and encoder software.

EXPECTATIONS:

1. As a salaried "exempt" employee of VARIS, Assistant Managers (AM) are expected to work at a minimum of 40 hours per week or a minimum of 80 hours every two week pay period. VARIS allows some flexibility of work schedules, however, AM's must work at least 5 hours per day. If less than 5 hours per day are worked, prior approval must be made. Approvals have to be entered into the VARIS time off calendar. AM's must be disciplined to work independently on a remote basis and have the ability to be flexible with the possibility of working greater than an 8 hour day.

2. AM's are expected to have each team member within their team achieving at a minimum a 15% find rate andcompleteat least 2.0 records per validation hour worked. A skill level improvement may be performed periodically by your manager..."A positive skill improvement analysis does not guarantee either an increase in compensation or continuing employment. Raises, if given, are based on a number of factors, such as VARIS, LLC performance and profitability, department or group performance and individual performance." (see Employee Handbook: Skill Improvement) AM's must also report as accurately as possible the total hours worked for each task.

3. Appeal responses are expected to be completed at the beginning of each work day. The time involved working on appeal responses is included within the total validation hours worked, not counted separately. AM's assure that all appeals for their team are complete on time. AM's assist other AM's in achieving a quick company wide appeal response.

4. An AM assists CVS's in producing strong and high quality rationales for any coding change that affects the DRG assignment; using proper grammar, spelling, and punctuation. Rationales should include ICD-9-CM Coding Conventions, Official Coding Guidelines, and AHA Coding Clinic advice to support the DRG change. Rationale letters are written at a level that conveys professionalism and subject matter expertise.

5. An AM assists CVS's to improve their quality of work and have no more than 2 cases per month (per employee) that are identified as a CVS oversight (or A3). Focused closed case reviews must be at a minimum of 90% accuracy rate. (Refer to the Quality Monitoring Policy and Procedure dated 2/2013)

6. AM's are expected to attend monthly CVS meetings. Only exceptions are for vacation, sickness or situations where prior approval has been made. If an AM misses a meeting they are required to review the team agenda and contact their Manager for important updates.

7. AM's are required to work on their coding skills on their own time to be professionally ready for their specific job at VARIS (including ICD-10).

8. AM's are expected to demonstrate commitment to the VARIS values as described in the employee handbook.

NOTE: The position expectations outlined above are in no way to be construed to be all encompassing.

This is an exempt position. The salary range is between $105,000 and $110,000 USD

For Salary position only:The salary range is for Base Salary.Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

What values we'll share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results
  
  

At Machinify, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative and accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please contact our People Operations team atMachinify_Careers@machinify.com. See our Candidate Privacy Notice at:https://www.machinify.com/candidate-privacy-notice