Role and Responsibilities
The DRG Validation Auditor is a valued member of the Penstock Audit team, responsible for reviewing inpatient claims and ensuring that the DRG paid is fair and accurate, based on the documentation in the medical record and the application of ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, policies, and Coding Clinic advice. The DRG Validation Auditor upholds the standards of honesty, excellence, and innovation that are central to the Penstock mission.
- Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify discrepancies between the physician documentation, the clinical picture depicted in the record, the codes billed, and the resulting DRG
- Appropriately uses industry-recognized references to support review findings, including the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics
- Writes complete, clear, and accurate rationale to support audit determinations,
citing specific information from the record, and referencing appropriate guidelines, policies, regulations, and/or Coding advice
- Keeps abreast of coding, clinical, regulatory, and other industry changes that impact Penstock auditing and/or that suggest new audit opportunities
- Maintains focus on the identification and development of new audit concepts
- Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels
- Participates in focused training to learn new auditing skills across a myriad of clinical and coding scenarios
- Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate
- Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater
📌 DRG Validation Auditor (Bardi)
🏢 SFNet
📍 Bardi