What are the responsibilities and job description for the DRG Validator & Appeals Reviewer-Clinical Doc Improvement position at The MetroHealth System (Cleveland, OH)?
Location: METROHEALTH MEDICAL CENTER
Biweekly Hours: 80.00
Shift: 8:00-4:30
The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.
Summary
Performs secondary clinical chart reviews, resolves DRG discrepancies, and educates clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy and improvement of capture of additional comorbid conditions. Conducts concurrent and retrospective medical record review on defined patient populations to identify opportunities to improve documentation accuracy. Reviews DRG downgrades and strategic CDI appeals, and responds to payor audits and inpatient downgrade requests when necessary. Upholds the mission, vision, values and customer service standards of the MHS.
Qualifications
Required: Bachelor’s degree in nursing or LPN, certified coder or Physician (MD / DO) with CDI experience in DRG validation or DRG downgrade activities, or any equivalent combination of education, training and experience in addition to experience noted below. Minimum of 5 years as Clinical Documentation Integrity Specialist or; - CDIP or CCDS Certification with minimum of 3 years of CDI experience or; - CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications and treatments, provider documentation requirements according to the rules of Medicare, Medicaid, and commercial payors, and a solid understanding of hospital acquired conditions (HAC’s), patient safety indicators (PSI’s) and mortality models. Experience with encoder and DRG assignments (MS and APR). Current working knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system. Excellent communication skills, with ability to listen and understand client request and needs while employing tact and effectiveness. Possesses CDIP or CCDS Certification or obtains within 1 year of hire. Strong analytical, organizational and time management skills. Ability to conduct meaningful conversations and /or presentations with providers in all situations. Ability to work independently and as a member of an interdisciplinary team. Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds Preferred: Currently licensed or licensed by endorsement as a LPN, Registered Nurse, MD or MD equivalent. Minimum 5 years acute inpatient clinical experience Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job-related documents. Ability to use computer.
Biweekly Hours: 80.00
Shift: 8:00-4:30
The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.
Summary
Performs secondary clinical chart reviews, resolves DRG discrepancies, and educates clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy and improvement of capture of additional comorbid conditions. Conducts concurrent and retrospective medical record review on defined patient populations to identify opportunities to improve documentation accuracy. Reviews DRG downgrades and strategic CDI appeals, and responds to payor audits and inpatient downgrade requests when necessary. Upholds the mission, vision, values and customer service standards of the MHS.
Qualifications
Required: Bachelor’s degree in nursing or LPN, certified coder or Physician (MD / DO) with CDI experience in DRG validation or DRG downgrade activities, or any equivalent combination of education, training and experience in addition to experience noted below. Minimum of 5 years as Clinical Documentation Integrity Specialist or; - CDIP or CCDS Certification with minimum of 3 years of CDI experience or; - CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications and treatments, provider documentation requirements according to the rules of Medicare, Medicaid, and commercial payors, and a solid understanding of hospital acquired conditions (HAC’s), patient safety indicators (PSI’s) and mortality models. Experience with encoder and DRG assignments (MS and APR). Current working knowledge of Official Coding Guidelines, Coding Clinic and federal updates to the DRG system. Excellent communication skills, with ability to listen and understand client request and needs while employing tact and effectiveness. Possesses CDIP or CCDS Certification or obtains within 1 year of hire. Strong analytical, organizational and time management skills. Ability to conduct meaningful conversations and /or presentations with providers in all situations. Ability to work independently and as a member of an interdisciplinary team. Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds Preferred: Currently licensed or licensed by endorsement as a LPN, Registered Nurse, MD or MD equivalent. Minimum 5 years acute inpatient clinical experience Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job-related documents. Ability to use computer.