Manager/Senior Manager - DRG Audit - Medical Coding - US Healthcare Payer Claims

Role Overview:

- Good understanding of US Healthcare Payer Claims & Medical coding

- Expert in auditing of hospital Inpatient claims

- Strong understanding of CMS payment policies and provider contracts

- Proficient in healthcare reimbursement methodologies

- Good analytical and communication skills

Responsibilities:

- Serve as subject matter expert and analyze claims payments as per Payer and CMS payment guidelines

- Conduct Inpatient DRG and APC coding quality checks

- Maintain knowledge of coding and billing requirements and regulatory changes

- Responsible for the accurate and thorough clinical investigation of potential fraud and abuse involving commercial and government lines of business

- Provide ideas to technical team of potential overpayment cases

- Ability to effectively interface with all levels of coding and auditing personnel (internal / external) and customers

- Quality check of claims adjudication and payments

- Work with analytics team to identify and automate repetitive tasks

- Quick turnaround using logical understanding of data

- Tracking and reporting of assigned tasks for internal and external stakeholders

Candidate Profile:

- 10+ years of experience in pre-payment and post-payment audit of US Healthcare Claims

- Must be CCS / CPC certified

- Must have worked on facility coding operations (IP DRG, ED, ER, SDS)

- Comprehensive knowledge on US health care industry, Institutional and Professional Claims

- Subject matter expert and analyze medical billing as per Payer, State and CMS guidelines

- In-depth technical knowledge of ICD-9-CM, ICD-10-CM, CPT & Revenue Codes coding conventions, AP-DRG, APR-DRG, MS-DRG and APC assignment, Present on admission guidelines, secondary diagnoses classification for MCCs/CCs, MDCs, E/M leveling, Medical terminology and anatomy and physiology

- Expertise in complex clinical coding/reviewing assignments, difficult investigations and highly visible issues

- Excellent knowledge of utilization management and preauthorization guidelines

- Thorough knowledge of payment rules hierarchy, fee schedule configuration and their impact on payment

- Capability to provide inputs to technical team with potential cases of overpayment in Institutional and Professional medical bills

- Preferred experience in data mining techniques using SAS/SQL/R or other similar language

- Superior skills to effectively communicate and negotiate across the business and external health care environment

- Demonstrate ability to interact effectively with non-technical clients and internal teams

- Must be a dependable and reliable player, able to work independently and as part of a goal oriented team with a positive attitude

- Must have strong analytical, reasoning, organizational and management skills