Job Description

Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required) Join to apply for the Payment Integrity DRG Coding & Clinical Validation Analyst role at Excellus BCBS. Job Description The Payment Integrity DRG Coding & Clinical Validation Analyst position requires extensive experience in acute facility-based clinical documentation and inpatient coding, with a strong understanding of MS‑DRG and APR‑DRG payment systems. Responsibilities include reviewing medical records for accurate provider documentation to support principal diagnoses, comorbidities, complications, secondary diagnoses, surgical procedures, and POA indicators. The analyst validates coding and DRG assignment accuracy, ensuring physician documentation aligns with hospital coded data and adheres to CMS and other regulatory standards. Essential Accountabilities Level I Analyzes and audits acute inpatient claims, integrating medical chart coding principles and clinical guidelines. Applies advanced ICD‑10 coding expertise and industry knowledge to substantiate conclusions. Adheres to official coding guidelines, coding clinic determinations, and CMS regulatory mandates. Establishes national and best‑practice benchmarks, measuring performance against them. Ensures accurate payment by independently using DRG grouper, encoder, and claims processing platform. Manages case volumes and review/audit schedules, prioritizing case loads per management assignment. Demonstrates integrity by supporting the Lifetime Healthcare Companies’ mission, values, and Corporate Code of Conduct. Maintains respect for member privacy per corporate privacy policies. Exhibits reliable attendance as required. Performs other functions as assigned by management. Level II Performs complex audits or projects with minimal direction or oversight. Acts as an expert in medical coding and record review, overseeing complex assignments and challenging customers. Supports leadership in projects related to divisional/departmental strategies and initiatives. Participates and represents in audits, payment methodologies, and contractual agreements with cross‑functional teams or business partners. Serves as a mentor to new hires. Engages on department committees, both internal and external. Level III Provides expertise in developing audit data criteria. Acts as a lead, offering training, guidance, complex performance analysis, and coaching to team members on continuous quality improvement. Resolves escalations in partnership with Payment Integrity staff. Provides backup support for management as necessary. Minimum Qualifications Associate or bachelor’s degree in Health Information Management (RHIA or RHIT) or Nursing. Three (3) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings. Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and comprehensive knowledge of medical claims billing/payment systems and coding terminology. Maintained coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC) as a condition of employment. Intermediate analytical and problem‑solving skills with awareness of business analysis trends. Intermediate knowledge of PC, software, auditing tools, and claims processing systems. Level II (Additional to Level I Qualifications) Five (5) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings. Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and advanced knowledge of medical claims billing/payment systems. Demonstrated ability across multiple skills, products, processes, and systems. Demonstrated leadership of initiatives with occasional guidance from management. Advanced analytical, problem‑solving, and judgment skills. Advanced knowledge of PC, software, auditing tools, and claims processing systems. Level III (Additional to Level II Qualifications) Eight (8) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings. Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and expert knowledge of medical claims billing/payment systems. Demonstrated leadership skills. Expertise as a subject‑matter expert or consultant to other departments. Ability to work independently and lead key business initiatives. Expert proficiency in auditing skillset and managing complex assignments. Expert proficiency in project management and presentation skills. Physical Requirements Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Compensation Range(s) Level I: Grade E4 – $65,346 – $117,622 Level II: Grade E5 – $71,880 – $129,384 Level III: Grade E6 – $79,068 – $142,322 The salary range indicated is the minimum and maximum of the salary range for each level. Actual salary will vary based on factors such as budget, experience, education, and internal equity. The posted salary range reflects one component of our total rewards package, which may include health and dental insurance, retirement plan, wellness program, paid time off, and holidays. #J-18808-Ljbffr Excellus BCBS

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