Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Roles & Responsibilities:
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
Duties and 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 System’s 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 facility’s 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. Other duties as assigned
Bachelor’s Degree in Nursing preferred
Registered Health Information Administrator or Registered Health Information Technician or equivalent experience preferred
Certified Coding Specialist Certification (CCS, CCS-P) required
10 years experience, to include 3+ years of medical/surgical coding and 3+ years of DRG appeal.
Strength Through Diversity
The Mount Sinai Health System believes that diversity and inclusion is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize healthcare delivery together.
We work hard to recruit and retain the best people, and to create a welcoming, nurturing work environment where you have the opportunity and support to develop professionally. We share the belief that all employees, regardless of job title or expertise, have an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospitals, including Mount Sinai Beth Israel, Mount Sinai Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.