DRG Validator (Assistant Director of Health Information Management), Clinical Doc & Coding Quality

About NYC Health + Hospitals

Empower Every New Yorker — Without Exception — to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city’s five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

Under the direction of Revenue Cycle Services, analyzes provider documentation, claims data, and coding on all diagnoses and procedures to ensure accuracy of diagnosis related grouping (DRG). The reviewer assures that the most accurate and descriptive ICD-10, CPT and HCPCS codes support the patient’s treatment and reflects severity of illness/risk of mortality. The second level reviewer also performs quality review of medical records, contributes to and validates the appropriateness of code and DRG assignment in order to facilitate consistency, accuracy and efficiency in claims processing, data collection and quality reporting.

General tasks and responsibilities will include:

1. Performs secondary level reviews to validate the completeness, accuracy, and specificity of code assignments for inpatient records in accordance with established coding guidelines and enterprise policies and procedures for appropriate DRG assignment. Ensures that all documented diagnoses and procedures are properly coded.
2. Validates the completeness, accuracy, and specificity of code assignments for emergency, outpatient and ambulatory surgery records in accordance with established coding guidelines to support HCC capture and CRGs.
3. Participates in data quality reviews on inpatient records to validate the ICD-10 codes, MS-DRG, and APR-DRG, identify missed secondary diagnoses and procedures, PSIs, HACs and ensures compliance with all DRG mandates and reporting requirements. Analyze reports and identifies trends and statistical significance in quality metrics that will assist with focused as well as organizational process improvement.
4. Participates in the denials and appeals process by reviewing cases denied and making the determination whether or not a case is appealable by using pre-established criteria, based facility policies and procedures. Ensures denials are responded to in a timely manner. Provides feedback to facility coders, validators and physician advisors on opportunities in collaboration with CDI.
5. Assists in the development, implementation, and management of organizational strategy, initiatives, and/or budget and performance standards; communicates organizational objectives and goals.
6. Identifies and reports on cases with documentation inadequacies, inconsistencies, and other issues with opportunities for improvement and collaborates with enterprise CDI reviewers to provide feedback and education to facility coders, DRG validators and CDIs.
7. Generates physician queries as needed in order to obtain clarification of medical record documentation. Validates that physicians have been queried according to established procedure. Provide feedback to facilities on missed query opportunities in collaboration with CDI.
8. Serves as departmental representative through participation in various facility and corporate wide committees, work groups, and/or initiatives. Assists in interdisciplinary efforts to review existing documentation and coding policies and procedures and makes necessary recommendations for improvement.
9. Instructs physicians, nurses, health information management staff, and other appropriate personnel regarding documentation requirements as related to coding.
10. Educate and mentors facility coding and validation staff. Provides orientation and boot camp training which includes new topics in coding (inpatient and outpatient), chart review, reimbursement and regulatory changes. Provides readiness assessments of new coding staff.
11. Performs coding quality audits of records for ICD-10-CM, CPT, and PCS, as well as MS/APR DRGs assignment to ensure functions of the CDI and coding team are performed with a high degree of accuracy.
12. Reviews coding edits for accuracy and provides feedback and education.
13. Identify trends and patterns in coding and documentation variances, monitor quality and provide education to ensure compliance with pertinent regulations and guidelines.
14. Research coding updates, new procedures, and disease pathophysiology and documentation requirements. Provide presentation/educational materials (recognized resources) to CDI and Coding staff.
15. Implement coding initiatives, goals and objectives for all facilities. This position oversees all ongoing activities related to the development, implementation and maintenance of inpatient and outpatient coding policies.
16. Ensures all coding and CDI staff abides by the standards of ethical coding as set forth and updated by AHIMA and ACDIS.
17. Performs all related assignments, as assigned

Department Preferences

• At least 2 years’ experience as a DRG Validator with a minimum of 3 years’ experience coding in an acute care setting.
• Strong organizational skills, ability to build and lead a team.
• Excellent written and oral communication skills.
• Strong administrative experience.
• Familiarity with revenue cycle and electronic medical records systems

Responsibilities

1.Three (3) years of clinical experience as a Registered Professional Nurse (RN) and an additional two (2) years of Clinical Documentation experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or

2. One (1) year of clinical experience as a Nurse Practitioner (NP) or Physician Assistant (PA) and an additional two (2) years of Clinical Documentation experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or 

3. Medical School Graduate; and two (2) years of medical record review, utilization review or case management experience; and valid certification from a nationally accredited organization in Coding or Clinical Documentation; or 

4. Valid Registered Health Information Administrator (RHIA) credential from the American Health Information Management Association (AHIMA) or a Registered Health Information Technician (RHIT) credential from AHIMA; and three (3) years of satisfactory experience in Diagnosis-Related Group (DRG) validation and coding; or

5. High school diploma or its educational equivalent; and valid coding certificate from a nationally accredited association (i.e., Certified Coding Specialist (CCS) from AHIMA or Certified Professional Coder (CPC)); and six (6) years of satisfactory experience in coding, abstracting medical records and DRG validation in a healthcare environment.

How To Apply

If you wish to apply for this position, please apply online by clicking the “Apply Now” button.

If applying online, please include your cover letter in the same file attachment with your uploaded resume.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees’ Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs

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