Job Description

Overview Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required) – Excellus BCBS Role involves review of medical records to validate coding and DRG assignment accuracy, with a strong understanding of MS-DRG and APR-DRG payment systems and inpatient coding principles. The analyst will evaluate provider documentation supporting principal diagnosis, co-morbidities, complications, secondary diagnoses, surgical procedures, and POA indicators to ensure hospital coded data is accurate. Essential Accountabilities Level I: Analyzes and audits Acute inpatient claims; applies medical chart coding principles, clinical guidelines, ICD-10 coding expertise, and independent work style to substantiate conclusions. Adheres to official coding guidelines, Coding Clinic determinations, CMS and regulatory requirements; requires expert DRG and ICD-10 coding knowledge. Establishes national and best-practice benchmarks and measures performance against them. Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platforms. Manages case volumes and audit schedules, prioritizing workload as assigned by Management. Upholds the organization\'s mission and values, and maintains member privacy in line with corporate policies. Maintains regular attendance; performs other functions as assigned by management. Level II (in addition to Level I): Performs complex audits or projects with minimal direction; acts as an expert in reviewing medical coding and documentation; oversees complex assignments and challenging issues. Supports leadership in divisional/departmental initiatives; participates in audits and cross-functional projects; mentors new hires. Represents department on internal/external committees as needed. Level III (in addition to Level II): Provides data-criteria development for audits; leads training and guidance; serves as expert resource for escalations; backup management support as needed. Minimum Qualifications Note: Roles are differentiated by knowledge, skills, and responsibility level including independent and complex assignments; includes development and promotional pathways. All Levels Associate or bachelor’s degree in health information management (RHIA or RHIT) or a Nursing degree. Three (3) years’ experience in claims auditing, quality assurance, or recovery auditing of (MS/APR) DRG coding for hospital or other acute facility setting. Three (3) years of working experience with ICD-10-CM, MS-DRG, and APR-DRG; broad knowledge of medical claims billing/payment systems, provider guidelines, and coding terminology. Coding Certification maintained as a condition of employment: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC. Analytical and problem-solving skills; stays current with industry trends in business analysis. Intermediate knowledge of PC, software, auditing tools, and claims processing systems. Level II qualifications (in addition to Level I): Five (5) years’ experience in claims auditing, quality assurance, or recovery auditing of (MS/APR) DRG coding; extensive experience with ICD-10-CM, MS-DRG, APR-DRG; broad knowledge of medical claims systems. Ability to lead initiatives with minimal guidance; advanced analytical and judgment skills; advanced software and systems knowledge. Level III qualifications (in addition to Level II): Eight (8) years’ experience in claims auditing, quality assurance, or recovery auditing; leadership and expert-level capabilities; ability to work independently and manage complex assignments; expert proficiency in analytics and project management. Physical Requirements Ability to work prolonged periods seated or standing at a workstation and using a computer. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. In support of the Americans with Disabilities Act, this job description lists only essential responsibilities and qualifications. Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. Compensation Range(s) Level I: Grade E4 — Minimum: $65,346; Maximum: $117,622 Level II: Grade E5 — Minimum: $71,880; Maximum: $129,384 Level III: Grade E6 — Minimum: $79,068; Maximum: $142,322 The posted salary range is a component of the total rewards package and may vary based on budget, experience, knowledge, and education, as well as internal equity. #J-18808-Ljbffr Excellus BCBS

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