DRG Nurse Auditor (remote, work)

Carewise Health helps organizations improve the personal health of employees and control healthcare costs. Our industry-leading health and wellness programs help members build the skills they need to achieve and sustain optimum health. Medical Bill Review ensures that health plans and self-insured employers are billed accurately for the care their members receive. Headquartered in Louisville, Ky., Carewise Health employs approximately 300 registered nurses, health coaches, clinicians, medical directors and other committed professionals.

Carewise Health provides a generous benefits package including:

Medical Insurance

Dental Insurance

Life Insurance

Vision Insurance

Paid Vacation

Paid Holidays

Paid Sick Days

Short Term Disability

Long Term Disability

401K Plan With Company Match

Tuition Reimbursement

Employee Assistance Program

All benefits are effective on the 29th day of employment with the exception of tuition reimbursement and STD/LTD, which is effective after 90 days of employment.

Attention Staffing Agencies: This position is not open for agency submittals. Any candidate submitted without HR approval will be considered an applicant of Carewise Health, not the agency. All Agency Candidates must first be submitted to HR.

EOE Disability/Veterans

Required Skills
ESSENTIAL FUNCTIONS

(Responsibilities/Accountabilities)

Reviews all cases decoding all diagnosis and procedures and comparing to bill summary to assure charges are in appropriate areas.

Verifies that primary diagnosis is the reason for admission.

Verifies that all complicating conditions are appropriate and documented in medical records.

Verifies that the sequencing of the diagnostic codes are appropriately assigned.

Verifies that DRG grouping is appropriate based on documented diagnosis and procedures.

Verifies accuracy of original claim allowance utilizing clients base rates, relative weights, and other reimbursement exceptions.

Identifies in writing any changes to the coding or DRG with the medical facility and obtain a signed agreement.

Clearly communicate in writing clinical rationale and/or coding rules to substantiate recommended coding & DRG change.

Reevaluate medical record and formulate responses based on appeals received by providers.

Maintains open communication with team, clients, and providers.

All other duties as assigned.

REQUIREMENTS

(Knowledge, Skills, Abilities)

Required Experience:

-Diploma in nursing required (Associate or Bachelors degree in nursing preferred)

-Active unrestricted nursing license in state of employment

-3 years of clinical nursing experience

-DRG audit experience

-DRG coding experience

-Skilled in Word, Excel and Outlook

-Excellent typing skills

-Must be able to work independently with minimal supervision

-Strong verbal and written communication skills

-Must be able to complete and pass a pre hire assessment

Preferred Experience:

-Coding Certification

-Healthcare claim audit knowledge in the following areas a strong plus: High Cost Specialty $ NOC Infusions, High-cost Implants & Supplies, One Day Admissions, Readmissions, ER Visits, End Stage Renal Disease and HAC/Never Events

-Knowledge of outpatient billing

-Working knowledge of InterQual criteria a plus

Position requires the candidate to be detail oriented and able to manage with tight deadlines. Must have the ability to prioritize and organize tasks and shift priorities as needed.

This position also requires some travel as needed for onsite audits, company, and/or client meetings

Required Experience
One to two years DRG Auditing experience required.