Work Shifts

9:00 A.M - 5:00 P.M

Duties & Responsibilities

SUMMARY OF DUTIES AND RESPONSIBILITIES:

Under the direction of Revenue Cycle Services, the reviewer analyzes provider documentation, claims data, and assigned codes for all diagnoses and procedures to ensure accurate Diagnosis-Related Group (DRG) assignment. This role ensures that the most precise and comprehensive ICD-10-CM/PCS, CPT, and HCPCS codes appropriately support the patient's clinical care and accurately reflect severity of illness and risk of mortality.

Serving as a second-level reviewer, the individual conducts comprehensive quality reviews of medical records; validates the appropriateness of coding and DRG assignment; and provides expert guidance to promote consistency, accuracy, and efficiency in claims processing, data integrity, 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

Minimum Qualifications
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.

Department Preferences

• Computer skills
• Copy Machines
• Fax Machines
• Strong understanding of inpatient case mix index drivers and how documentation and coding decisions influence reimbursement, quality metrics, and overall organizational performance.
• Understand escalation pathways for coding discrepancies, clinical validation challenges, and payer audits, as well as apply second-level review methodologies and peer review standards to ensure inter-rater reliability.
• Working awareness of common documentation deficiencies, provider documentation patterns, and enterprise standardization practices is essential to promote consistency and defensible coding outcomes.
• Must understand the downstream effects of coding decisions on billing, quality reporting, and public measures, while maintaining appropriate data governance, audit trails, and documentation to support external reviews and appeals.
• Must have at least 2 years' experience as a DRG Validator with a minimum of 3 years' experience coding in an acute care setting.
• In-depth understanding of MS-DRG methodology and Medicare inpatient prospective payment system (IPPS)
• Expert knowledge of ICD-10-CM/PCS coding guidelines and Official Coding Guidelines
• Strong knowledge of clinical validation principles, including severity of illness (SOI) and risk of mortality (ROM)
• Familiarity with payer policies, medical necessity criteria, and denial trends impacting inpatient claims
• Knowledge of CDI workflows, physician query standards, and documentation best practices
• Understanding of quality indicators, including PSI, HAC, and mortality measures affected by coding and documentation
• Working knowledge of EHR systems, coding encoders, and auditing/validation tools
• Knowledge of compliance, audit, and regulatory requirements related to inpatient coding and reimbursement.

Benefits

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
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discounts programs
• Commuter Benefits Programs

If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.