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The DRG Validation Auditor will be a member of the CGI Audit Team, with responsibility for reviewing medical records to determine the accuracy of coding and reimbursement for clinical services rendered to beneficiaries of health plans, including Commercial and Government Clients. The DRG Validation Auditor will be trained in auditing and charged with rendering appropriate, well-supported, and thoroughly-documented decisions which may result in the identification of improper payments (overpayments and underpayments) on paid claims on behalf of the client from various providers of clinical services, including but not limited to acute care, long-term acute care, acute rehabilitation, and skilled nursing facilities, as well as other provider types and care settings. The DRG Validation Auditor is prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in methods for review of the medical record and other provider documentation, application of appropriate coding guidelines, and use of the documentation format tailored to the client’s requirements. Ongoing training and education are provided specific to audit processes, coding and reimbursement changes, and other topics as indicated. The review process may result in changes to the payment for previously-rendered services, and decisions are rendered through a well-defined process which requires the Auditor to incorporate coding experience and knowledge, as well as critical thinking skills in order to assess available information and render a decision. The DRG Validation Auditor reports to a DRG Validation Team Leader, who provides support, feedback, and guidance to the Auditor. Audit performance review and quality assurance are provided through a well-defined review and quality management program.
Your future duties and responsibilities:
• Reviews inpatient medical records to validate, assignment and sequencing of ICD-9-CM and ICD-10 diagnosis and procedure codes, discharge status codes, and DRG assignment. Reviews/Follows proper procedure for referral to Clinical Nurse Auditor or Physician Advisor, as applicable
• Provides a detailed rationale for every medical record review resulting in a DRG or outpatient Review Results letter, including supporting references. Utilizes proper reference material, standards, and guidelines for coding.
• Correctly interprets and utilize reference materials, including coding standards and guidelines, CPT Assistant, Coding Clinic for Outpatient, NCDs, LCDs, client payment policies
Required qualifications to be successful in this role:
The DRG Coder should possess current AHIMA or AAPC credentials (RHIT, RHIA, CCS-P, CPC, CPC-H/COC), along with robust critical thinking and problem-solving skills. The auditor demonstrates extensive knowledge of ICD-10 and CPT/HCPCS coding, DRG and APC reimbursement, with a minimum of five years of coding experience.
Previous experience training and mentoring junior-level coders, and/or peer-review auditing is highly desired, as is experience with Clinical Documentation Improvement (CDI) initiatives, and familiarity with Charge Master.
A working knowledge of computer functions, Microsoft Office (Outlook, Word,Teams, Excel) applications, and Windows operating systems is required in order to manage audit processes. The coding auditor utilizes skills to write a well-reasoned review in narrative style, with accurate spelling, grammar, punctuation, and sentence structure. The Auditor must be able to work independently, adapt to changing priorities, and meet department productivity standards and deadlines.
Est. Salary Range (Colorado Only): $53,000.00-70,000.00*
*Disclaimer: In accordance with Colorado’s Equal Pay for Equal Work Act, effective January 1, 2021, a good faith hourly or base salary range must be posted for all positions where the work may be performed in the state of Colorado. Therefore, this good faith salary range will only apply where this described position will be performed in the state, and should not be considered the compensation range in other locations or for other positions.
At CGI we call our professionals “members” to reinforce that all who join our team are, as owners, empowered to participate in the challenges and rewards that come from building a world-class company. CGI’s benefits include:
• Competitive base salaries
• Eligibility to participate in an attractive Share Purchase Plan (SPP) in which the company matches dollar-for-dollar contributions made by eligible employees, up to a maximum, for their job category
• 401(k) Plan and Profit Participation for eligible members
• Generous holidays, vacation, and sick leave plans
• Comprehensive insurance plans that include, among other benefits, medical, dental, vision, life, disability, out-of-county emergency coverage in all countries of employment;
• Back-up child care, Pet insurance, a Member Assistance Program, a 529 college savings program, a personal financial management tool, lifestyle management programs and more
- Communication (Oral/Written)
What you can expect from us:
Build your career with us.
It is an extraordinary time to be in business. As digital transformation continues to accelerate, CGI is at the center of this change—supporting our clients’ digital journeys and offering our professionals exciting career opportunities.
At CGI, our success comes from the talent and commitment of our professionals. As one team, we share the challenges and rewards that come from growing our company, which reinforces our culture of ownership. All of our professionals benefit from the value we collectively create.
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Learn more about CGI at www.cgi.com.
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CGI is an equal opportunity employer.
Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity and gender expression, familial status, political affiliation, genetic information, or any other legally protected status or characteristics.
CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at US_Employment_Compliance@cgi.com. You will need to reference the requisition number of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a requisition number will not be returned.
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All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.
CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI’s legal duty to furnish information.