DRG Specialist

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DRG Specialist Job ID: 8266557413 Status: Full-Time Regular/Temporary: Regular Shift: Day Job Work Arrangement: Remote Facility: Corporate Revenue Cycle Department: Rev Cyc Coding Union Position: No Salary Range: $ 27.89-48.21 USD APPLY NOW SAVE JOB UPMC Corporate Revenue Cycle is hiring a DRG Specialist to work on inpatient auditing within our Coding Department. This position will be a work-from-home position working during standard business hours Monday through Friday. In this role, you will review clinical documentation within the medical record to ensure that all patient resource utilization, diagnostic complications and co-morbidities have been coded in compliance with coding guidelines, third-party payer and OIG regulations. Responsibilities: Review and evaluate focused UPMC DRG medical records for accurate DRG assignment to ensure that all documented principal and secondary diagnoses, including all complications and co-morbidities, and procedures are accurately coded and sequenced according to coding and compliance guidelines. Meet with coding management as scheduled to review progress, discuss problems, and initiate new programs or activities relative to the information obtained from these reports. Function as a resource person to respond to special audits and projects assigned by Management or requested by other departments. Perform audits as requested by internal departments and outside payers/agencies Investigate, correct (if necessary), and respond to requests for record review relative to discharge disposition, admit or discharge date, invalid codes, etc. from requesting departments to ensure timely, accurate reimbursement. Investigate and address research accounts requiring V70.7 code assignment. Review focused charts at a rate in accordance with departmental standards. Facilitate compliance to the Medicare 72-Hour Rule by identifying and investigating related admissions, making the appropriate adjustments to the coding system, contacting the Admitting department for registration issues, and reporting outcomes to the Patient Business Services department for appropriate reimbursement. Coordinate DRG reimbursement issues among coding, nursing administration, Patient Business Services, medical staff, case management, and other ancillary departments directly affected by DRG assignment. Track and report quality statistics of the coding personnel from focus chart audits and report this information to the Coding Manager on a monthly basis. Provide coding staff with updates on any coding issues and educational information as necessary. Counsel/train coders on problems when necessary in coordination with the Coding Manager and/or Coding Specialist and assist in correcting deficiencies in DRG assignment. Prepare monthly productivity reports of DRG revenue profiles to identify total amount of optimization and missed opportunities. Attend and participate in Committee meetings as requested. Investigate and respond to payment and/or DRG Assignment denials by Workers Compensation, and other insurers. Identify and report issues and trends to the coding management. Focus emphasis of educational presentations on accurate and thorough documentation necessary to support the coding of diagnoses that were treated, monitored and evaluated and procedures that were performed during an episode of care. Review billing data when conducting focused chart audits to ensure it is complete and accurate. Prepare and present in-service training on accurate DRG assignment for coding personnel, the medical staff, physician extenders (PAs, CRNPs), nursing case management and ancillary departments. Assist the Coding Manager with auditing coders’ work as requested. Formulate physician queries that present indications, utilizing clinical judgment, of a diagnosis that is not clearly documented in the medical record and request appropriate documentation to support the additional diagnosis. Qualifications: 3 years of previous clinical acute care medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG’s; OR completion of Registered Health Information Administration program (RHIA) or Registered Health Information Technician (RHIT) or CCS AND 3 years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required. 3 years of inpatient coding experience is preferred. Knowledge of computer technology, quality assurance activities, DRG methodology background is highly preferred. Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required. Licensure, Certifications, and Clearances: Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN) Act 34 UPMC is an Equal Opportunity Employer/Disability/Veteran APPLY NOW SAVE JOB SHARE JOB CAREER GROWTH Grow Your Nursing Career Spanning over 20 clinical specialties and more than 50 unique nursing roles, every nurse at UPMC can achieve and advance their goals with the My Nursing Career Ladder. Whether you’re looking to progress to an elevated role or continue your education, UPMC equips nurses with the resources, feedback, leadership, and benefits to help you succeed and achieve your career goals. Here’s how a few nurses have grown their careers through the years at UPMC: Clyde C. Michelle B. Clyde C. Clyde C. As a Professional Staff Nurse, Expert at UPMC Muncy, Clyde is a great example of someone who has taken advantage of UPMC’s My Nursing Career Ladder to grow his career while remaining in the same hospital location. Clyde’s Career Journey: ⦁ 2017: Professional Staff Nurse – UPMC Muncy ⦁ 2021: Sr. Professional Staff Nurse – UPMC Muncy ⦁ 2022: Sr. Professional Staff Nurse II – UPMC Muncy ⦁ 2022-present: Professional Staff Nurse, Expert – UPMC Muncy Michelle B. Michelle B. In her current role as a Professional Staff Nurse, Expert at UPMC Presbyterian, Michelle cares for patients with chronic and ongoing health issues as part of a Medical-Surgical unit. Michelle enjoys the daily change that Med-Surg nursing brings, and has found a career path that is interesting, meaningful, and full of opportunity. Michelle’s Career Journey: ⦁ 2019: Staff Nurse – UPMC Presbyterian ⦁ 2020: Professional Staff Nurse – UPMC Presbyterian ⦁ 2021: Professional Staff Nurse, BSN – UPMC Presbyterian ⦁ 2021: Sr. Professional Staff Nurse, BSN – UPMC Presbyterian ⦁ 2022: Sr. Professional Staff Nurse II, BSN – UPMC Presbyterian ⦁ 2023: Professional Staff Nurse, BSN, Expert – UPMC Presbyterian INSURANCE SERVICES DIVISION OF UPMC Advance Your Future A career with UPMC means more than just caring for patients – when you’re a part of UPMC Insurance Services Division, it means caring for more than four million insurance members, too. UPMC Insurance Services Division offers a full range of health insurance products and services to our network across the country, providing peace of mind, better health, and financial security to our members, along with limitless career opportunities and a rewarding mission to those on our team. About Us Opportunities on Our Team Recognized for Excellence Jump-Start Your Career About Us About UPMC Insurance Services Division As an integrated health care provider-insurer, UPMC goes beyond patient care to provide insurance products and services to millions of members. Our team partners with UPMC and community network providers to deliver knowledge and expertise that provides the highest quality care at the most affordable price, supporting our members through service, communication, and more. Fast Facts: We provide insurance products and services to over more than four million members. UPMC’s Insurance Services Division offers a full range of health insurance options including UPMC Health Plan, Workpartners, UPMC for Life , UPMC for You , UPMC for Kids , UPMC Community HealthChoices, and Community Care Behavioral Health. UPMC Health Plan is among the nation’s fastest-growing health plans. Opportunities on Our Team Opportunities on Our Team We’ve got a job that’s just right for you! UPMC Insurance Services Division team offers a vast array of career paths and opportunities , from career areas like customer service, data analytics, and information technology and even patient care roles like social work, nursing, and care management. Whether in non-clinical or patient-facing roles, our team impacts patients and members by providing quality experiences before, during, and after their care, building relationships in a unique and meaningful way. Search Jobs Recognized for Excellence Recognized for Excellence Be a part of an award-winning team! UPMC Insurance Services Division has been recognized for outstanding care and service with awards that include: U.S. News and World Report named UPMC for Life a “Best Insurance Company for Medicare Advantage” in Pennsylvania for 2024. The Human Rights Campaign Foundation has named UPMC Health Plan an “Equality 100 Leader in LGBTQ+ Workplace Inclusion” for 2023–2024. UPMC for Life ranked #1 in Customer Satisfaction* among Medicare Advantage Plans in Pennsylvania by J.D. Power. The Ethisphere Institute named UPMC as one of the World’s Most Ethical Companies for the sixth consecutive year. *Results are based on award-eligible plans in Pennsylvania by J.D. Power. For J.D. Power 2024 award information visit, jdpower.com/awards . Jump-Start Your Career Jump-Start Your Career Looking to launch a career with longevity and opportunity? With countless entry-level opportunities for recent graduates, along with tools and resources that empower you as you learn and grow, UPMC Insurance Services Division is the perfect place to get a career started. Interested in taking your career to new heights? Our career paths and advancement opportunities will provide you with chances to achieve your goals at every step. Search Jobs BENEFITS AND LIFE AT UPMC Why Work Here We know that you have many options when choosing where to build your career. So why choose UPMC? We can think of a few reasons. Work-Life Balance Finding the ideal balance to manage the important elements in your life. Development & Opportunities Enhancing your career through continued learning opportunities and/or advancement. Compensation Receiving competitive pay for the work that you do – base pay, merit, and premium pay. Performance & Recognition Rewarding performance that supports the goals and mission of UPMC. Benefits Providing assistance and security to meet the current and future needs of you and your family. Work-Life Balance Finding the ideal balance to manage the important elements in your life. Development & Opportunities Enhancing your career through continued learning opportunities and/or advancement. Compensation Receiving competitive pay for the work that you do – base pay, merit, and premium pay. Performance & Recognition Rewarding performance that supports the goals and mission of UPMC. Benefits Providing assistance and security to meet the current and future needs of you and your family. Benefits that Matter to You We’re committed to providing benefits that meet your needs and support your well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Benefits that Matter to You We’re committed to providing benefits that meet your needs and support your well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Benefits that Matter to You We’re committed to providing our employees with benefits that meet their needs and support their well-being in all areas of life. Earn over 5 weeks of paid time off every year Affordable medical, dental & vision coverage Student loan assistance and tuition reimbursement options Earn up to 8% of your eligible pay in retirement contributions from UPMC Employer-paid life insurance Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Two weeks of paid parental leave Family planning resources Tuition assistance for dependents Comprehensive health care for dependents Emergency child and elder care options Flexible work arrangements Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Two weeks of paid parental leave Family planning resources Tuition assistance for dependents Comprehensive health care for dependents Emergency child and elder care options Flexible work arrangements Support for You – and Your Family Your career doesn’t impact just you, but the people you care about, too. We’re making sure your career works for the whole family. Flexibility to choose the shifts and work arrangements that work best for your lifestyle Two weeks of paid parental leave Family planning resources Comprehensive health care for dependents Emergency child and elder care options A Culture That Cares At UPMC, you can find a home among people who share your passions and care about who you are. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for veteran engagement A Culture That Cares At UPMC, you can find a home among people who share your passions and care about who you are. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for veteran engagement A Culture That Cares UPMC is a place where you can find a home, no matter your gender, race, sexual orientation, age, or culture, and where you can meet people who share your passions and care about you. Employee resource groups Awards for champions of dignity & respect Center for Workplace Culture and Engagement Programs for Veteran Engagement Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Up to $6,000 of annual tuition assistance Ongoing learning via LinkedIn Learning Accelerated career pathways for growth Robust instructor-led education and learning pathways Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Up to $6,000 of annual tuition assistance Ongoing learning via LinkedIn Learning Accelerated career pathways for growth Robust instructor-led education and learning pathways Tools to Reach Your Potential Once you become a member of our team, the journey doesn’t stop there. UPMC is committed to supporting your growth and helping you build the career of your dreams. Unlimited educational possibilities, including no-cost BSN and MSN programs Robust career ladders for every nurse – no matter your specialty, location, or career stage Up to $6,000 of annual tuition assistance Ongoing learning opportunities Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites Dozens of career ladders to climb International locations State-of-the-art technology Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites Dozens of career ladders to climb International locations State-of-the-art technology Expansive Opportunity Where do you want to go with your career? Wherever it is, UPMC can take you there. 100,000 employees 40+ hospitals and 800+ doctors’ offices and outpatient sites International locations State of-the-art technology LEARN MORE ABOUT BENEFITS * Note: Benefits described may not be applicable to all staff. Read More about Nursing at UPMC Never Too Late: Kendra’s UPMC Journey After working as a nursing assistant for 16 years, Kendra took the leap to go back to nursing school and become an RN. LEARN MORE Med-Surg Nursing in 4 Words: UPMC Nurses Share We asked our nurses to shed some light on what Med-Surg nursing means to them. Get to know Med-Surg nursing – in four words – from UPMC nurses! LEARN MORE Where Passion Meets Purpose: Leah’s UPMC Story Starting her career in Environmental Services, Leah shares how she fell in love with health care and became a nurse. LEARN MORE Read More about UPMC Insurance Services Division Why Data Analytics Matter to UPMC’s Mission In UPMC Insurance Services Division, analysts work to understand, innovate, and improve the products and services UPMC provides. LEARN MORE The Game of Life is About More Than Winning: Eddie’s UPMC Outlook Eddie S. shares how his passion for football, fishing, and friendship shapes his life and his career with UPMC Health Plan. LEARN MORE From the U.S. Army to UPMC Health Plan We asked our nurses to shed some light on what Med-Surg nursing means to them. Get to know Med-Surg nursing – in four words – from UPMC nurses! 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