<p>Site: Mass General Brigham Health Plan Holding Company, Inc.</p> <p>Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.</p> <p>Job Summary</p> <p>Perform DRG validation and quality audit on claims, providing coding expertise in the application of medical and reimbursement policies within the claim adjudication process through document review, interpretation of state and federal mandates, applicable benefit language, coding requirements, and consideration of relevant clinical information with a focus on overpayment identification.</p> <p>This role recovers inaccurately paid DRG claims submitted by providers, with an increasing number of contracts being moved from a percentage of charge to DRG-based reimbursement.</p> <p>Qualifications</p> <p>Responsibilities</p> <ul> <li>Perform DRG validation and quality audit on claims, providing coding expertise in the application of medical and reimbursement policies within the claim adjudication process through document review, interpretation of state and federal mandates, applicable benefit language, coding requirements and consideration of relevant clinical information with a focus on overpayment identification. </li><li>Utilize expert clinical knowledge and judgement to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance. </li><li>Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment. Ability to write clearly and succinctly in a variety of communication settings and styles. Excellent communication and presentation skills across various levels and through multiple channels (oral, written, conversational). Strong quantitative and analytical skills. </li><li>Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. Ability to view the long-range trends and cycles of the business and industry and see the "big picture." </li><li>Review and analyze facility and professional claims in support of MGBHP's medical and payment policies and CMS guidelines. Apply knowledge and experience during decision-making process. Complete and document audits based on established guidelines. Provide input on and research of claims challenged by the providers. </li><li>Identify and provide analytical data on billing trends/issues for potential areas of recoveries. Regularly reviews to identify enhancement to the audit methodology and documentation requirements. Provide clinical support and expertise to the other investigative and analytical areas. Identify potential audit concepts and notify Manager of Provider Audit of any leads, in support of next steps or escalation to outside agencies. </li><li>Maintain and manage daily case review assignments, with a high emphasis on quality. Work in a high-volume production environment that is matrix driven. </li></ul> <p>Additional Job Details (if applicable)</p> <p>Qualifications:</p> <ul> <li>Associate's degree required or the equivalent combination of training and experience, plus 3-5 years of related experience. Bachelor's degree preferred </li><li>Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), CPC-H (hospital) or CCS (Certified Coding Specialist). </li><li>Nursing license preferred. </li><li>5+ years of DRG Validation role performing DRG claims auditing, quality assurance, or recovery auditing required. </li><li>Thorough knowledge of ICD-10, ICD-10-PCS, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS, and Revenue Billing Codes. </li></ul> <p>Knowledge, Skills, and Abilities</p> <ul> <li>Superior Microsoft Suite and Excel Skills required. </li><li>Being a strong team player. </li><li>Excellent project management skills. </li><li>Familiarity with the regulatory environment for financial services. </li><li>Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. </li><li>Strong work ethic and focus on quality work. </li><li>Understanding of general accounting principles. </li><li>Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. </li><li>Strong verbal, active listening, and written communication skills required. </li><li>Excellent interpersonal skills, including the ability to influence others at all levels of an organization. </li><li>Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. </li><li>Unquestionable integrity </li></ul> <p>Working Conditions:</p> <ul> <li>This is a remote role that can be done from most US states </li><li>Monday through Friday, standard business hours (ET) are required </li></ul> <p>Remote Type</p> <p>Remote</p> <p>Work Location</p> <p>399 Revolution Drive</p> <p>Scheduled Weekly Hours</p> <p>40</p> <p>Employee Type</p> <p>Regular</p> <p>Work Shift</p> <p>Day (United States of America)</p> <p>EEO Statement:</p> <p>Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.</p> <p>Mass General Brigham Competency Framework</p> <p>At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.</p>