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DRG/IBR Nursing Auditor

Devoted Health

Devoted Health

United States · Remote
Posted on Saturday, June 22, 2024

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

Job Description

A bit about this role:

  • At Devoted, we know that one of the most important ways we will build trust is by ensuring we pay claims accurately and on time.

  • We also have a fiduciary responsibility to protect the Medicare Fund and this role will play an integral part in doing that.

  • The DRG/IBR Nursing Auditor performs inpatient reviews by validating accuracy of the DRG code assignment completeness, POA, discharge status, etc. to ensure accurate payment to our providers.

  • The DRG/IBR Nursing Auditor determines if a discrepancy exists in the coding and clinical documentation using standard documentation guidelines applicable to the program.

  • This Work-from-Home position will primarily perform desk audits, validate vendor identification, and perform dispute reviews.

Your responsibilities and impact will include:

  • Conduct initial audit reviews to validate billed diagnoses and DRG code are supported by medical records.

  • Conduct initial IBR reviews for billing accuracy.

  • Record Audit results and document finding notes based on policies using professional clinical resources.

  • Perform provider appeals reviews and render coding decision to either uphold or overturn original finding.

  • Review questionable encoder results, complex cases and appeal reviews with program manager, and facilitate referrals to clinical department as needed.

  • Propose new audit concepts supported by your research and analysis.

  • Define new audit concept criteria and test and validate new concepts developed by analytics team.

Required skills and experience:

  • Associate or Bachelor's degree in Nursing (active / unrestricted license)

  • Understanding of the medicare DRG payment methodology

  • 2-3 years of Claims auditing experience

  • Strong verbal and written communication skills

  • Understanding of CMS guidelines related to Medicare Advantage claims

Desired skills and experience:

  • CCS, CPC, or RHIA (preferred)

  • 3-5 years of inpatient hospital coding experience with ICD 10 CM/PCS, MS-DRG

Salary range: $54,000 - $91,000 / year

Our ranges are purposefully broad to allow for growth within the role over time. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered may depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

  • Employer sponsored health, dental and vision plan with low or no premium

  • Generous paid time off

  • $100 monthly mobile or internet stipend

  • Stock options for all employees

  • Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

  • Parental leave program

  • 401K program

  • And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.