DRG Specialist

DRG Specialist

UPMC Corporate Revenue Cycle is hiring a DRG Specialist to work on inpatient auditing within our Coding Department. This position will be a work-from-home position working during standard business hours Monday through Friday. To be considered, this role requires three years of coding experience.

In this role, you will review clinical documentation within the medical record to ensure that all patient resource utilization, principal diagnosis, secondary diagnoses, and PCS procedures have been coded accurately and completely in compliance with coding guidelines, third-party payer and OIG regulations.

Responsibilities:

• Review and evaluate focused UPMC DRG medical records for accurate DRG assignment to ensure that all documented principal and secondary diagnoses, including all complications and co-morbidities, and procedures are accurately coded and sequenced according to coding and compliance guidelines.
• Meet with coding management as scheduled to review progress, discuss problems, and initiate new programs or activities relative to the information obtained from these reports. Function as a resource person to respond to special audits and projects assigned by Management or requested by other departments. Perform audits as requested by internal departments and outside payers/agencies
• Investigate, correct (if necessary), and respond to requests for record review relative to discharge disposition, admit or discharge date, invalid codes, etc. from requesting departments to ensure timely, accurate reimbursement. Investigate and address research accounts requiring V70.7 code assignment. Review focused charts at a rate in accordance with departmental standards.
• Facilitate compliance to the Medicare 72-Hour Rule by identifying and investigating related admissions, making the appropriate adjustments to the coding system, contacting the Admitting department for registration issues, and reporting outcomes to the Patient Business Services department for appropriate reimbursement.
• Coordinate DRG reimbursement issues among coding, nursing administration, Patient Business Services, medical staff, case management, and other ancillary departments directly affected by DRG assignment.
• Track and report quality statistics of the coding personnel from focus chart audits and report this information to the Coding Manager on a monthly basis.
• Provide coding staff with updates on any coding issues and educational information as necessary.
• Counsel/train coders on problems when necessary in coordination with the Coding Manager and/or Coding Specialist and assist in correcting deficiencies in DRG assignment.
• Prepare monthly productivity reports of DRG revenue profiles to identify total amount of optimization and missed opportunities.
• Attend and participate in Committee meetings as requested. Investigate and respond to payment and/or DRG Assignment denials by Workers Compensation, and other insurers.
• Identify and report issues and trends to the coding management.
• Focus emphasis of educational presentations on accurate and thorough documentation necessary to support the coding of diagnoses that were treated, monitored and evaluated and procedures that were performed during an episode of care.
• Review billing data when conducting focused chart audits to ensure it is complete and accurate.
• Prepare and present in-service training on accurate DRG assignment for coding personnel, the medical staff, physician extenders (PAs, CRNPs), nursing case management and ancillary departments.
• Assist the Coding Manager with auditing coders' work as requested.
• Formulate physician queries that present indications, utilizing clinical judgment, of a diagnosis that is not clearly documented in the medical record and request appropriate documentation to support the additional diagnosis.

Qualifications:

• Three years of previous clinical acute care medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG's; OR completion of Registered Health Informations Administration program (RHIA) or Registered Health Information Technician (RHIT) or CCS AND three years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required.
• Knowledge of computer technology, quality assurance activities, DRG methodology background is highly preferred.
• Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required.

Licensure, Certifications, and Clearances:

• Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN)
• Act 34

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran