Auditor Clinical Validation DRG
New
United StatesFull-TimeMiddle
SalaryCompetitive hourly compensation (approximately $45.67/hour, annualized around $95K)
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Job Details
- Experience
- 5–7+ years
- Required Skills
- Microsoft Excel
Requirements
- Associate or bachelor’s degree in Nursing (active, unrestricted license) OR Health Information Management (RHIA/RHIT) OR equivalent experience with high school diploma/GED and 5+ years in auditing or healthcare claims.
- One or more active certifications required: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.
- 5–7+ years of experience working with ICD-9/10, MS-DRG, APR-DRG, and inpatient coding and billing systems.
- Strong knowledge of medical necessity criteria, payer reimbursement rules, and regulatory compliance standards (CMS and coding clinic guidance).
- Proficiency with standard office tools such as Word, Excel, Access, and collaboration platforms like Microsoft Teams.
- Strong analytical thinking, attention to detail, and ability to assess complex medical documentation accurately.
- Excellent written and verbal communication skills for audit documentation and findings.
- Ability to work independently in a remote environment with a secure, dedicated workspace and reliable high-speed internet.
Responsibilities
- Conduct comprehensive inpatient claims audits using clinical records, coding guidelines, and regulatory standards to validate DRG/APR-DRG assignments.
- Apply advanced ICD-10, MS-DRG, APR-DRG, and related coding knowledge to support audit findings and ensure compliance with payer and CMS guidelines.
- Utilize proprietary audit systems and tools to document findings, generate audit determinations, and prepare formal audit correspondence.
- Maintain required productivity levels while ensuring accuracy, quality, and adherence to audit standards.
- Identify claims outside of standard audit scope that may present additional recovery opportunities or risk areas.
- Contribute to continuous improvement efforts by suggesting enhancements to audit tools, methodologies, and workflows.
- Complete assigned responsibilities, special projects, and performance objectives in alignment with organizational expectations.
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