Location: New York,NY, USA
Description The DRG Appeals Analyst - CDI Liaison is responsible for analyzing medical records, claims data, and coding on all diagnoses and procedures (both medical and surgical) to assure properly assigned diagnostic related grouping (DRG) for purposes of appeal. This individual assures that the most accurate and descriptive codes from the listings of International Classification of Diseases, Ninth Revision; Clinical Modification (ICD-9-CM American Medical Association Current Procedural Terminology (CPT-4) Coding system; and Healthcare Common Procedure Coding System (HCPCS) codes supporting the patient's treatment have been applied to the claim. Responsibilities 1. Analyzes denials and determines when an appeal should be filed to the payor. Determines whether the coding assigned by the client was properly assigned based upon review of the medical documentation and application of the coding guidelines. 2. Develops and applies appeal arguments to defend the coding decisions of our clients while being able to address and refute the coding determination made by the CMS contractor. 3. Drafts appeal letters, including the coding argument, to support our client's coding decision. 4. Provides feedback to management regarding trends or patterns noticed in client coding for discussion with client. 5. Collaborates with the MS Health Systems Physician Advisor and HIM team to review denials and coordinate the appeal process. As front-line auditor, reviews cases denied and renders determinations whether or not case is appealable by using pre-established criteria, based on third party administrator requirements. 6. Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for billed services beyond what is found in the medical record. 7. Performs data quality reviews on inpatient records to validate the ICD-9-CM codes, MS-DRG or AP-DRG, APR-DRG, identify missed secondary diagnoses and procedures, PSIs, HACs and ensures compliance with all DRG mandates and reporting requirements. Analyzes reports and identifies trends and statistical significance in quality metrics that will assist with focused as well as organizational process improvement. 8. Reviews and analyzes PSIs and HACs to ensure that the coding assignment was properly assigned based upon review of the medical documentation and application of the coding. 9. Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and documentation improvement. 10. Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement, and participates with the planning and development of educational programs directed towards improving documentation. 11. Creates and monitors quality improvement (such as PSIs, HACs) and APR-DRG accuracy to identify patterns, trends, and variations in the facilitys frequently assigned DRG reports or specific areas impacting US News and World Report ratings. Once identified, this individual evaluates the causes of the change or problems, and takes appropriate steps in collaboration with coding staff, HIM management staff, CDI leadership and the hospital administrative staff. 12. Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places. 13. Responsible for remaining current with the latest healthcare technology and coding advise through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for outpatient reimbursement and coding. 14. Participates in education programs to maintain up to date coding skills. 15. Performs other duties as assigned or required. Qualifications Bachelors Degree in Nursing preferred. Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or equivalent experience preferred. 10 years experience, to include 3+ years of medical/surgical coding and 3+ years of DRG appeal. Must have excellent working and current knowledge of federal and the All-Payer DRG reimbursement methodology. Demonstrated knowledge of ICD-9 codes, DRG and CPT coding. Employer Description Strength Through Diversity The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai's unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by: Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential. Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination. Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers. At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally. Explore more about this opportunity and how you can help us write a new chapter in our history! About the Mount Sinai Health System: Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high Honor Roll status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's Best Children's Hospitals ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's The World's Best Smart Hospitals ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism. EOE Minorities/Women/Disabled/Veterans Compensation The Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $116718 - $175078 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.
Bachelors Degree in Nursing preferred. Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or equivalent experience preferred. 10 years experience, to include 3+ years of medical/surgical coding and 3+ years of DRG appeal. Must have excellent working and current knowledge of federal and the All-Payer DRG reimbursement methodology. Demonstrated knowledge of ICD-9 codes, DRG and CPT coding.
1. Analyzes denials and determines when an appeal should be filed to the payor. Determines whether the coding assigned by the client was properly assigned based upon review of the medical documentation and application of the coding guidelines. 2. Develops and applies appeal arguments to defend the coding decisions of our clients while being able to address and refute the coding determination made by the CMS contractor. 3. Drafts appeal letters, including the coding argument, to support our client's coding decision. 4. Provides feedback to management regarding trends or patterns noticed in client coding for discussion with client. 5. Collaborates with the MS Health Systems Physician Advisor and HIM team to review denials and coordinate the appeal process. As front-line auditor, reviews cases denied and renders determinations whether or not case is appealable by using pre-established criteria, based on third party administrator requirements. 6. Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for billed services beyond what is found in the medical record. 7. Performs data quality reviews on inpatient records to validate the ICD-9-CM codes, MS-DRG or AP-DRG, APR-DRG, identify missed secondary diagnoses and procedures, PSIs, HACs and ensures compliance with all DRG mandates and reporting requirements. Analyzes reports and identifies trends and statistical significance in quality metrics that will assist with focused as well as organizational process improvement. 8. Reviews and analyzes PSIs and HACs to ensure that the coding assignment was properly assigned based upon review of the medical documentation and application of the coding. 9. Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and documentation improvement. 10. Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement, and participates with the planning and development of educational programs directed towards improving documentation. 11. Creates and monitors quality improvement (such as PSIs, HACs) and APR-DRG accuracy to identify patterns, trends, and variations in the facilitys frequently assigned DRG reports or specific areas impacting US News and World Report ratings. Once identified, this individual evaluates the causes of the change or problems, and takes appropriate steps in collaboration with coding staff, HIM management staff, CDI leadership and the hospital administrative staff. 12. Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places. 13. Responsible for remaining current with the latest healthcare technology and coding advise through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for outpatient reimbursement and coding. 14. Participates in education programs to maintain up to date coding skills. 15. Performs other duties as assigned or required.