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 I/II/III (RHIA, RHIT, CCS, or CIC Certification Required) role at Excellus BCBS. The Payment Integrity DRG Coding & Clinical Validation Analyst is responsible for reviewing medical records for appropriate provider documentation to support diagnosis, co‑morbidities, complications, secondary diagnoses, surgical procedures, POA indicators to validate coding and DRG assignment accuracy. The analyst ensures physician documentation supports hospital coded data and uses MS‑DRG, APR‑DRG payment systems. Essential Accountabilities Level I: Analyzes and audits acute inpatient claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in audit activities. Applies advanced ICD‑10 coding expertise. Adheres to official coding guidelines, CMS policy, and compliance standards. Establishes benchmarks, utilizes DRG grouper, encoder, and claims processing platform. Manages case volumes and audit schedules. Upholds integrity, privacy, and attendance expectations. Level II: Builds on Level I duties, performs complex audits or projects with minimal direction. Oversees challenging assignments, engages customers, mentors new hires, participates in department initiatives and committees, and represents the division on cross‑functional teams. Level III: Leads audits, develops data criteria, trains and consults team members, resolves escalations with Payment Integrity staff, and supports management as needed. Minimum Qualifications Associate or bachelor’s degree in health information management (RHIA or RHIT) or Nursing. Three (3) years of experience in claims auditing, quality assurance, or recovery auditing of DRG coding for hospital or acute facility setting. Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG systems. RHIA or RHIT credential, Inpatient Coding Credential – CCS or CIC (to be maintained). Intermediate analytical and problem‑solving skills; proficiency with PC, software, auditing tools. Level II Additional Qualifications Five (5) years of experience in DRG coding audit and quality assurance for hospital or acute facility setting. Demonstrated leadership and advanced analytical skills. Proficiency with PC and claims processing systems. Level III Additional Qualifications Eight (8) years of experience in DRG coding audit, quality assurance, or recovery auditing for hospital or acute facility setting. Demonstrated leadership, subject‑matter expertise, and project management skills. Expert proficiency in auditing and analytical skills, handling complex assignments. Physical Requirements Prolonged sitting or standing at a workstation; use of computer. Travel within the health‑plan service region for meetings/training as needed. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. 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 veteran status. Compensation Range Level I: Grade E4 Minimum $65,346 – Maximum $117,622 Level II: Grade E5 Minimum $71,880 – Maximum $129,384 Level III: Grade E6 Minimum $79,068 – Maximum $142,322 Actual salary will vary by budget and experience. Package includes group health and dental insurance, retirement, wellness, paid time off, and holidays. Remote work may be considered on a case‑by‑case basis. #J-18808-Ljbffr Excellus BCBS

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