Senior Drg Validation Auditor

Goodroot is a community of companies committed to delivering more access to better healthcare at a lower cost. With a growing group of brands including, but not limited to AlignRx, Coeo, and Sola, Goodroot is reshaping healthcare for good, one system at a time. Our growing products and services portfolio includes pharmacy benefit consulting, pharmacy benefit coalition, health plan options for self-funded employer groups, patient navigation, and hospital financial assistance consulting. Learn more at www.goodrootinc.com. Goodroot is an Equal Opportunity Employer.

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get the accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care, and improving access for all. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense. We geek out over building and perfecting software that helps health plans succeed, but we also understand the irreplaceable value of human intelligence. Named by Buffalo Business Journal as one of the best places to work!

Penstock is an affiliate company of Goodroot, which launches and grows companies dedicated to putting patients back in the center of healthcare.

Job Description:

The Senior DRG Validation Auditor is a seasoned leader on the Penstock Audit team, responsible for reviewing inpatient claims and ensuring that the DRG paid is fair and accurate, based on the documentation in the medical record and the application of ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, and Coding Clinic advice. The Senior Clinical Auditor embodies the standards of honesty, excellence, and innovation that are central to the Penstock mission and serves as a resource and mentor for other Audit Team members.

Responsibilities include, but are not limited to:

• Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify discrepancies between the physician documentation, the clinical picture depicted in the record, the codes billed, and the resulting DRG.
• Appropriately uses industry-recognized references to support review findings, including the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics
• Writes complete, clear, and accurate rationale to support audit determinations, citing specific information from the record, and referencing appropriate guidelines, policies, and/or Coding Clinic advice.
• Prepares written responses and/or participates in conference calls regarding payor or provider questions about Penstock audit findings.
• Completes provider appeals and conducts quality assurance reviews as required.
• Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics.
• Helps analyze audit results to identify opportunities for edit refinement and/or internal training
• Keeps abreast of coding, clinical, regulatory, and other industry changes that impact Penstock auditing and/or suggest new audit opportunities.
• Participates in keeping the DRG team informed of coding updates and industry changes that impact DRG validation.
• Contributes to the creation and maintenance of the Penstock Clinical Parameters library.
• Maintains focus on the identification and development of new audit concepts.
• Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels
• Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate.
• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers.
• Serves as a Payment Integrity subject matter expert for Penstock team members and the Goodroot organization.
• Meets or exceeds Penstock’s performance and quality standards.

Qualifications and Education Requirements:

• Minimum of an associate degree
• Current AHIMA coding credential(s): RHIT, RHIA, or CCS
• 5 or more years of ICD-10 inpatient coding and/or auditing experience (or demonstrated equivalent) with a preference for auditing experience
• Comprehensive understanding of inpatient coding guidelines, Coding Clinic content, and DRG grouping mechanics
• Strong current clinical knowledge
• Familiarity with Clinical Documentation Integrity practices
• Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII
• Ability to conduct independent research using credible sources
• Demonstrated working knowledge of Microsoft Word, Excel, and PowerPoint
• Ability to apply critical thinking skills to record reviews
• Ability to work independently, manage workload, and adapt to shifting priorities
• Excellent communication skills, both oral and written
• Comfortable working in an ever-changing environment
• Able to work Eastern time zone hours
• Secure and private home office with reliable high-speed internet connection

Preferred Skills:

• Bachelor’s degree
• 7+ years of ICD-10 coding and auditing experience
• CCS credential
• CDIP or CCDS credential
• Nursing education and/or experience
• Intermediate or expert-level Excel skills

Job Type: Full-time

Pay: From $95,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• Remote

Work Location: Remote