The DRG Clinical Educator is responsible for developing and delivering team education to support (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves determining the most appropriate clinical validation criteria for use, accessing the team’s clinical acumen and ability to clinically validate all impacting diagnoses.  Awareness of applicable coding guidelines, along with ability to interpret and apply guidelines appropriately. Medical record review prowess and ability to identify compliance concerns associated with queries and their responses. Expert level understanding of the APR and MS DRG payment methodology validation strategies.

Essential Duties and Responsibilities:

• Assesses and identifies skills, competencies and areas of learning and instruction needed for all DRG recovery audit staff. Develops cost-effective education, training and quality assurance programs that will improve quality and productivity outcomes. Develops, implements, and maintains tools to assess and measure DRG recovery audit staff against position specific competencies.
• Development of job aids and concept training materials and on-going education relating to new opportunities in the APR and MS DRG payment recovery industry.
• Provides oversight and participation with the planning and coordination of the orientation program for new hires; provides introduction to the program, clarifies program expectations and standards; provides prerequisite knowledge required; and assists to train in the basic job skills. Provides support for trainees, and acts as clinical SME resource for staff, providers, leadership team, and other healthcare professionals. Develops and maintains an educational calendar; facilitates tracking mechanisms for individual continuing education and orientation records for staff. Develops and conducts programs with educational materials, procedures and exercises that are task/function specific using a variety of learning and evaluation strategies for all staff.
• Monitors compliance through quality audits and data analysis promoting standardized practices.
• Designs and deploys an effective quality assurance program to identify and correct claims with aberrant results. Ensures feedback is provided to resolve the root cause of identified errors.
• Maintains current knowledge relating to DRG payment integrity industry by attending educational workshops/conferences, reviewing professional publications, establishing personal networks, and/or participating in professional societies. This will also include performing ongoing research to ensure compliance with clinical validation, coding and DRG validation standards and regulatory guidelines.
• Other duties as assigned.

Job Requirements:

Education (required)

• Equivalent experience of 5+ years’ experience in Clinical Documentation Improvement with additional 3+ years’ experience in inpatient claims auditing, quality assurance, and recovery auditing

Coding and Clinical Documentation Certifications (at least two of the following are desired)

• CCS - Certified Coding Specialist, or
• CDIP – Certified Documentation Improvement Practitioner
• CCDS – Certified Clinical Documentation Specialist

Experience

• Demonstrates ability to work efficiently and effectively with minimal direct supervision

• Exhibits high standards of quality and attention to detail
• Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
• Demonstrates superior knowledge of healthcare coding, billing and reimbursement
• Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations.
• Working knowledge of DRG clinical claim review

• Expert knowledge and understanding of clinical criteria documentation requirements to successfully substantiate code assignments
• Demonstrated subject matter expertise in all the following areas: APR-DRG and MS-DRG payment methodologies, industry standard clinical criteria, clinical review judgement, ICD-10-CM and PCS code sets, coding conventions, UHDDS definitions, Official Coding Guidelines, AHA Coding Clinic publications and AHIMA Practice Briefs, and ACDIS standards.

Computer Equipment and Software

• Experience working with multiple monitors
• Experience and success in a remote working environment
• Working knowledge of Windows office systems including full Microsoft Suite and Teams
• Advanced software skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various forms of software and experience engaging with development teams
• Experience with TruCode and 3M encoder/grouper applications.