QA - HIM Services

About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Roles and Responsibilities:

Auditing and reviewing medical documentation for appropriate ICD and CPT coding
and ensuring that codes tally with doctors’ diagnosis.
Asking explanation from physicians when code assignments are not straightforward or
documentation in the record is inadequate, ambiguous, or unclear for coding purposes
Ensuring compliance with medical coding policies and guidelines.
Be updated about new coding rules as codes change from time to time.
Collecting and distributing coding related information and billing issues.
Exceptional Knowledge of medical terminology, anatomy, physiology, disease
processes, and pharmacology.
Work as part of a team and achieve the team quality and productivity standards.

Required Expertise & Qualification:

Life Science graduation or any equivalent graduation with Anatomy/Physiology as
main subjects
3 to 5 years of work experience as a medical coder.
Any one of the following coding certifications CPC, COC, CRC, CPCP from AAPC CCS,
CCSP, CCA from AHIMA
Proficient computer skills.
Excellent communication skills, both verbal and written.
Strong people skills & Outstanding organizational skills.
Ability to maintain the confidentiality of information.

Job Title: Quality Auditor – Inpatient DRG

Experience: 5–10 years in Medical Coding (minimum 3 years specifically in Inpatient DRG coding/auditing)

1. Job Purpose

The IP-DRG Auditor is responsible for reviewing inpatient medical records to ensure that the assigned ICD-10-CM (Diagnoses) and ICD-10-PCS (Procedures) codes accurately reflect the patient’s clinical stay. The primary goal is to validate the MS-DRG (Medicare Severity) or APR-DRG (All Patient Refined) assignment to ensure compliance and optimized, legitimate reimbursement.

2. Key Responsibilities

Core Audit Functions:

• DRG Validation: Verify that the Principal Diagnosis is correctly identified according to the Official Coding Guidelines.
• MCC/CC Verification: Audit the chart for Major Complications/Comorbidities (MCC) or Complications/Comorbidities (CC) that impact the DRG weight and hospital payment.
• Surgical Review: Validate ICD-10-PCS codes, ensuring that the root operation, approach, and body part are accurately captured from the operative report.
• POA (Present on Admission): Ensure the accuracy of POA indicators to prevent Hospital-Acquired Condition (HAC) penalties.
• Discharge Status: Verify discharge status codes (e.g., home, skilled nursing, home health), as these can trigger "transfer" payment rules.

CDI & Query Management:

• Identify opportunities for Physician Queries where documentation is ambiguous, incomplete, or conflicting.
• Collaborate with Clinical Documentation Improvement (CDI) teams to bridge the gap between clinical language and coding requirements.

Feedback & Quality Improvement:

• Perform 100% "Pre-bill" audits for high-dollar DRGs or specific focus areas (e.g., Sepsis, Respiratory Failure, Cardiac procedures).
• Conduct "Root Cause Analysis" (RCA) on DRG shifts and provide educational feedback to the coding team.
• Keep the team updated on the IPPS (Inpatient Prospective Payment System) annual updates (effective every Oct 1st).

3. Technical Expertise Required

• Mastery of ICD-10-PCS: High proficiency in the 7-character grid system for inpatient procedures.
• DRG Logic: Deep understanding of how "Grouping" works (MS-DRG vs. APR-DRG).
• Clinical Knowledge: Strong understanding of pathophysiology and pharmacology (to recognize when a diagnosis is supported by the treatment/medication administered).
• Systems: Expertise in 3M 360 Encompass (the industry standard for DRG), Optum, and EHRs like Epic or Cerner.

4. Qualifications & Experience

Education:

• Bachelor’s/Master’s in Life Sciences (B.Pharm, Nursing, MBBS, BPT, etc.).

Mandatory Certifications:

• CCS (Certified Coding Specialist) - The most preferred certification for IP coding.
• CIC (Certified Inpatient Coder) - Highly valued for BPO/KPO roles.
• (Optional) CDIP or CCDS is a major plus if the role involves heavy clinical documentation review.

Work Experience:

• Proven experience in high-acuity facilities (Level 1 Trauma centers or large Teaching Hospitals).
• Experience with Denials Management (answering DRG-related clinical appeals) is highly desirable.

5. Key Performance Indicators (KPIs)

• Financial Accuracy: Ensuring the "DRG Shift" rate is within company standards.
• Coding Accuracy: Maintaining a minimum of 96% - 98% accuracy in diagnosis and procedure selection.
• Turnaround Time (TAT): Auditing charts within 24–48 hours to ensure the hospital's "Days in AR" (Accounts Receivable) is minimized.
• Query Rate: Maintaining an appropriate query rate to ensure documentation supports the billed DRG.

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.