STAR Medical Auditing Services

Outpatient & Inpatient Claim Validator

Are you a skilled and credentialed medical coding professional looking for an amazing team to join? Look no further! STAR Medical Auditing Services is hiring.

Outpatient & Inpatient Claim Validator (Remote)

JOB DESCRIPTION

The Outpatient & Inpatient Claim Validator position has an extensive background in both outpatient and inpatient coding for both ProFee and facility and has a high level of understanding in reimbursement guidelines, specifically an understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. This position is responsible for auditing inpatient and outpatient medical records on appeal, to determine if the prior denials are upheld or overturned. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding, medical necessity, MUE’s, and DRG assignment accuracy. Also, reviews appropriate assignment of diagnosis codes, CPT codes, E/M levels and applicable modifiers.

KEY RESPONSIBILITIES

  • Analyzes and Audits Claims. 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. Performs work independently.

  • Effectively utilizes audit tools. Utilizes proprietary auditing systems (e.g., Codify, TruCode, etc.) with a high level of proficiency to make audit determinations and generate audit rationales.

  • Meets or exceeds Standards/Guidelines for productivity. Maintains production goals set by the audit operations management team.

  • Meets or Exceed Standards/Guidelines for accuracy and quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation (writing). Such accuracy scores must be maintained at 97% or higher.

EXPERIENCE/QUALIFICATIONS

  • Must have one of the following AHIMA/AAPC certifications: CPC, CCS, RHIA, or RHIT

  • Extensive knowledge of medical terminology, anatomy and coding guidelines for ICD-10, PCS, CPT, Modifiers, etc.

  • Equivalent experience of 3+ years’ experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment.

  • 3+ years of working with ICD-10-CM, 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.

  • Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge of DRG, ICD-10, CPT, PCS, and HCPCS codes.

  • Requires working knowledge of and applicable industry-based standards.

  • Proficiency in Word, Access, Excel and other applications.

  • Excellent written and verbal communication skills.

desire qualities

  • Self-sufficient with strong analytical and research skills

  • Responsible and responsive

  • Strong attention to details

  • Excellent written and oral communication skills

  • Ability to manage multiple projects at once and work to meet deadlines

TECHNOLOGY REQUIREMENTS

  • Microsoft Word, Excel, PowerPoint & Outlook

  • Reliable high-speed internet service

STAR Medical Auditing Services LLC is an Equal Employment Opportunity / Affirmative Action employer and committed to creating a diverse environment.  All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.