This DRG Validation Auditor role supports Cross Claim Clinical Reviews (CCCR), performing prepay and retrospective audits with a focus on inpatient claim review, coding accuracy, clinical validation, and appropriateness of treatment setting and services delivered.
The role works an off-hour schedule of either 3 PM–11 PM ET or 11 PM–7 AM ET, including weekends and holidays.
Key responsibilities include auditing inpatient claims, documenting audit results, using proprietary audit tools, meeting productivity and quality standards, identifying new claim types, and recommending process improvements.
Education
- Associate or bachelor’s degree in Nursing with active/unrestricted license
- Associate or bachelor’s degree in Health Information Management with RHIA or RHIT
- Or high school diploma/GED plus 5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in DRG/clinical validation or a hospital environment
Certifications
- RHIA or RHIT
- CPC
- Inpatient coding credential such as CCS, CIC, CDIP, or CCDS
Experience
- 5 to 7+ years working with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG
- Strong knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology
- Expert knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes
- Familiarity with coding guidelines, Coding Clinic determinations, CMS rules, and regulatory compliance requirements
- Proficiency with Word, Access, Excel, Teams, and similar applications
- Strong written and verbal communication skills
Competitive benefits package including:
- Medical, dental, and vision coverage
- Disability and life insurance
- 401(k) savings plan
- Paid family leave
- 9 paid holidays per year
- 17–27 days of PTO per year depending on level and tenure
- Eligibility for discretionary bonus consideration
- Overtime pay for nonexempt hours over 40 per week, where applicable
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Salary Range
$95,000 - $95,000
Remote work allowed
Yes
Posted
3 weeks ago