The DRG Validation Auditor is a member of the CGI Healthcare Compliance, DRG Validation 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 is 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.
• This position can be located remotely anywhere in the U.S, and candidates must be willing to work in Eastern Time Zone hours.
• Reviews inpatient medical records to validate, assignment and sequencing of ICD-10 diagnosis and procedure codes, discharge status codes, Hospital Acquired Conditions (HACs), POA assignment, and DRG assignment.
• Provides a detailed rationale for every medical record review resulting in a DRG Review Results letter, including supporting references.
• Follows proper procedure for referral to Clinical Nurse Auditor or Physician Advisor, as applicable.
• Utilizes proper reference material, standards, and guidelines for coding.
• Provides input to the Edit Development team on claims selection criteria.
• Verifies data received from client and work to resolve discrepancies.
• If the contract requires onsite review, interacts with Providers and other personnel in a professional manner.
• Follows CGI policies and processes, completing Red Carpet, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.
• Communicates timely with Team Lead regarding illnesses, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.
• Complies with department standards regarding productivity and audit quality.
• Performs other duties as assigned.
• The DRG Validation Auditor possesses current AHIMA credentials (RHIT/RHIA/CCS), with current CCS (certified coding specialist) preferred.
• The Auditor demonstrates extensive knowledge of ICD-10-CM/PCS coding and DRG reimbursement, with a minimum of five (5) years of inpatient coding experience.
• Previous experience training and mentoring junior-level coders is highly desired.
• The DRG Validation Auditor must understand government and commercial provider reimbursement methodologies (MS-DRG and APR-DRG), and possesses strong clinical validation skills, as well as data analytic skills.
• A working knowledge of computer functions and applications such as Microsoft Office (Outlook, Word, Excel) and Windows operating systems is required in order to manage applications utilized in the audit process.
• The ability to write a well-reasoned review in a narrative style, with accurate spelling, grammar, punctuation, and sentence structure is required for success in the audit position.
• The auditor must be able to adapt to changing priorities in order to meet Client requirements, and is required to meet department productivity standards and deadlines.
• The auditor must be proactive and self-directed, self-sufficient in completing tasks, as well as detail-oriented, with a passion for life-long learning.
• The Auditor may be required to travel for additional training and on-site reviews on an as-needed basis.
CGI anticipates accepting applications for this position through November 30, 2024.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
*CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to: skill set level; experience and training; and licensure and certifications. CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $60,300 -$118,700.
At CGI we call our professionals “CGI Partners” 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:
CGI’s benefits are offered to eligible professionals on their first day of employment to include:
• Competitive compensation including profit participation program
• Comprehensive medical, dental, and vision benefits
• Basic life and accidental death & dismemberment insurance
• Matching contributions through 401(k) plan, and CGI share purchase plan
• Flexibility and paid accrued vacation leave, ranging from 10 to 20 days per year, based on job level, years of relevant prior experience, and years of service
• 10 paid holidays per year
• At least 80 consecutive hours of paid sick/safe leave (except where applicable state/local law requires more)
• Paid parental leave, ranging from 20 to 70 consecutive business days based on circumstances of leave and applicable laws
• Bereavement leave, ranging from 1 to 7 days per year based on relationship.
• Paid jury duty leave, up to time summoned
• Learning opportunities and tuition assistance
• Wellness and Well-being programs
For more detailed information about our benefits offerings visit Benefits | CGI Careers
Please note that the benefits listed above are subject to change based on the specific terms and conditions of the contract being supported.
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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, height, weight, or any other legally protected status or characteristics.
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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. Dependent upon role and/or federal government security clearance requirements, and in accordance with applicable laws, some background investigations may include a credit check. 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.