A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
Responsibilities Universal Health Services (UHS) - Western Region Consolidated Business Office (WCBO) The Western Region Consolidated Business Office delivers comprehensive insurance revenue services to our affiliated UHS facilities, encompassing billing, collections, cash posting, pre-access management, variance analysis, and customer service. Our dedication to associate satisfaction and growth is recognized by industry leaders, exemplifying our commitment to fostering a positive and inclusive workplace culture. Our associates can count on competitive salaries, top-tier medical, dental, and retirement benefits, career training, and support for continued professional development. The Western Region CBO is seeking a dynamic and talented Inpatient Coder for our Appeals department. The primary responsibility of the DRG Coder is to analyze third party coding audits of paid claims, draft detailed appeal letters, evaluate clinical level of care and review denial trends.
Qualifications Key Responsibilities include:
Perform DRG (Diagnosis Related Group) validation reviews in response to audits from third party payers. Review audit findings letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying payer clinical / coding rationale. Analyze medical records to obtain supporting clinical documentation for billed diagnosis codes. Write detailed appeal letters based on clinical findings to third party payers to prevent downgrade payment recoveries. Make decision to update DRGs or remote or add to billed diagnose codes based on clinical reviews Assign DRG audits to nurse auditors when coding audit is based on clinical criteria. Provide analysis and assistance as needed to the appeals department. Assist customer service with patient complaints related to coding issues on their medical bills. Provide a detailed charge/coding breakdown to assist with medical claims that need to be split billed based on various clinical scenarios. Manage multiple spreadsheets including DRG inventory and inventory returned from vendors. Maintain educational guidebooks for multiple department workflows. Assist with drafting and maintaining appeal letter templates. Identify audit trends and provide feedback to management and to UHS acute care facilities. Adherence to all applicable laws, regulations and guidelines. Other duties as assigned.
Benefit & Rewards Highlights:
Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans 401(K) with company match and discounted stock plan SoFi Student Loan Refinancing Program Career development opportunities within UHS and its 300+ Subsidiaries! Pet Insurance More information is available on our
