MEDICAL REVIEW ANALYST iHealth Technologies, Inc.
PRINCIPAL PURPOSE OF JOB:
The Medical Review Analyst performs complex inpatient / DRG claim audits as part of iHealth Technologies ongoing Claims Review Services associated with our client / health plan contracts. The Medical Review Analyst is a coding & auditing expert who reviews medical records to determine compliance of coding and documentation guidelines as well as correct DRG assignment on the claim.
ESSENTIAL JOB RESPONSIBILITIES:
Validates DRG assignment by reviewing the medical record, diagnoses, and procedures performed on inpatient claims.
Identifies deficiencies in medical record documentation, adherence to coding guidelines, and deviations client policy and/or clinical guidelines of practice that may further invalidate the claim.
Manages individual work queue of claims, and achieves or surpasses goals for volume throughput and quality.
--note, this position has both production and quality metrics--
Other Related Responsibilities
Maintains personal knowledge and supports team awareness of changes in coding, Medicare, Medicaid and clinical guidelines.
Maintains professional certifications.
Contributes to the general knowledge of the auditing team.
Supports training, product development, and audit defensibility programs.
Other duties as assigned.
Strong analytical and problem solving skills.
Flexible in thought and creative in approach.
Works with a sense of urgency
Communicates with ease up and down the chain of leadership
Professional with ability to properly handle confidential information
Ability to work well independently and in a team environment.
Ability to handle multiple tasks, prioritize and meet deadlines.
Excellent written and verbal communication skills.
Exhibits behaviors consistent with iHT Values.
Formal HIM education with national certification (RHIA, RHIT) preferred.
Industry recognized coding certification required (CCS or CPC-H preferred).
Minimum of five years progressive coding or coding review experience in ICD-9-CM with claims processing and data management responsibilities a plus.
Excellent oral and written communication skills and comprehensive knowledge of the DRG structure and regulatory requirements.
Prefer someone with past auditing experience or strong training background in coding and reimbursement.
Minimum of one year ICD-9-CM coding and abstracting experience in a health care environment or medical records department.
Knowledge of medical record practices, state and federal laws relating to release of medical information, ICD-9-CM and CPT coding systems, medical terminology to understand diagnoses and procedures, and the content and organization of a medical record.
Knowledge of anatomy, physiology and disease process to understand and interpret diagnoses and procedures contained within, discharge summaries, operative and laboratory reports and related medical documents.
Experience working with medical, nursing, and other allied health staff as well as external medical facilities requesting medical record information.
Must be able to sit and use a computer keyboard for extended periods of time.
Willingness for periodic travel related to training.
Remote employees must have an appropriate work environment, high speed internet access and telephone line.
This role does not have direct reports.
Clinical Quality Specialist
CRS Medical Director
other Medical Review Analyst
||Altanta, GA |