Manager, DRG Coding & Validation (RN)

Molina Healthcare•Long Beach, CA

12h

About The Position

Leads and manages team responsible for developing diagnosis-related group (DRG) validation tools and process improvements. Responsible for ensuring that member medical claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10 and/or current CPT codes, and accuracy of DRG or APC assignments. Contributes to overarching strategy to provide quality and cost-effective member care.

Requirements

At least 7 years clinical nursing experience, and at least 5 years experience in claims auditing, quality assurance, recovery auditing, DRG/clinical validation, utilization review and/or medical claims review, or equivalent combination of relevant education and experience.
At least 1 year health care management/leadership experience.
Registered Nurse (RN). License must be active and unrestricted in state of practice.
Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC).
Experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
Strong coding knowledge: DRG, ICD-10, CPT, HCPCS codes.
Ability to work cross-collaboratively in a highly matrixed environment.
Excellent verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

Certified Professional Coder (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
Experience in claims auditing, quality assurance, or recovery auditing, ideally in DRG/clinical validation.
Training and education experience.

Responsibilities

Oversees and provides subject matter expertise for the diagnosis-related group (DRG) validation program - leading a team responsible for developing and implementing DRG validation tools, workflow processes, training, auditing and production management resources.
Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines and industry knowledge to substantiate conclusions.
Utilizes Molina proprietary auditing systems with a high-level of proficiency to make audit determinations, generate audit letters and train team members on related processes.
Ensures that claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10-CM and/or CPT codes as well as accurate Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) assignment for timely and accurate reimbursement and data collection.
Audits inpatient medical records and generates high-quality claims payment to ensure payment integrity.
Performs clinical reviews of medical records and other documentation to evaluate issues related to coding and DRG assignment accuracy.
Manages medical claim review team nurses, ensuring operational goals and key performance indicators (KPIs) are met and maintained by team.
Ensures team members achieve the expected level of accuracy and quality for valid claim identification, decision-making and documentation; provides monthly feedback and develops workplans as appropriate.
Coordinates and conducts on-going training for all employees as needed; delegates to lead as appropriate to ensure new hires are trained.
Influences and engages direct and indirect reports as well as peers to achieve results.
Provides leadership and development to all workforce staff including assistance in development and training.
Identifies potential claims outside of the concept where additional opportunities may be available; suggests and develops high-quality, high-value concept and or process improvement tools.
Develops and maintains job aids, conducts quarterly reviews and updates as needed.
Escalates claims to medical directors, health plan teams, claims teams, and collaborates directly with variety of leaders throughout the organization.
Ensures coding guidelines as established within the health Information management department and according to National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.
Ensures appropriate care management guidelines around multiple procedure payment reductions and other mandated pricing methodologies specific to Medicaid are in place.
Supports the development of auditing rules within software components to meet care management regulatory mandates.