Position Summary:

The DRG Validator & Coding Compliance Liaison provides expert-level coding consultation and guidance for complex medical records that require further research and reference checking. This expert is responsible for creating consistency and efficiency in inpatient claims processing and data collection to optimize DRG reimbursement and facilitate data quality in hospital inpatient services; Subject Matter Expert (SME) related to quality of ICD-10 coding and evaluation of revenue impact and communicates findings to Revenue Cycle Team. Researches and advises HIM management regarding updates to coding classifications and reimbursement methodologies as these impact reimbursements. Conduct performance improvement activities regarding coding accuracy, completeness, data quality and integrity on flagged cases; identify issues in correct sequencing of codes and assignment of grouper payment methodology.

Essential Functions and Responsibilities Include the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.

2. Keeps abreast of all pertinent federal, state and WPH regulations, laws and policies as they presently exist and as they are changed or modified.

3. In conjunction with the Coding Manager, Assures timely transmission of coded data to Patient Accounts Department.

4. Serves as hospital resource on coding and DRG reimbursement.

5. Coordinating with the Coding Manager, oversees Inpatient compliance reviews as necessary; initiates education/or corrective actions, as needed.

6. Performs Focused Coding Compliance Audits as needed for regulatory purposes; e.g. OIG or when requested by the organization.

7. Shares findings of coding reviews with Coders on a regular basis; initiates/education or corrective actions as necessary.

8. Assures compliance with state regulatory and accreditations standards.

9. Participates in committees, task forces, projects as required.

10. Performs all other related duties as assigned.

Education & Experience Requirements

Associates Degree required. CCS Certification required; RHIA or RHIT credential preferred. Minimum of five (10) years of coding experience in acute care hospital Health Information Department with extensive exposure to CPT4 and ICD-10-CM-PCS coding, data entry and chart analysis required. Must have excellent understanding of coding guidelines and in depth understanding of MS-DRG, and APRDRG groupers to ensure optimal results for hospital to maintain high compliance and optimal reimbursement.

Core Competencies:

• Ability to build effective partnering relationships with HIM team, finance and payer representatives to problem solve and improve quality.

• Knowledge of various DRG groupings and reimbursement methodologies and impact of complications and co-morbid conditions on the grouping.

• Excellent critical thinking, verbal and written communication skills. Experience in writing action plans and appeals is a plus.

• Basic computer skills and knowledge of word processing, spreadsheet and database programs.

• Strong organizational and time management skills.

• Ability to multi-task and meet targets.

Physical/Mental Demands/Requirements & Work Environment

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.

• Manual dexterity is required for use of computer keyboard and mouse; Must be able to sit at computer terminal for extended amounts of time daily.

• Walking to different areas both inside and offsite locations • Must be able to concentrate during times of increased noise level, changes in temperatures