DRG Clinical Auditor

Essential functions

• Review medical records to determine billing accuracy through verification of coding and supporting clinical documentation
• Check physician notes supporting assigned DRGs
• Conduct audits to ensure accurate reimbursement and identify potential savings
• Review previous audits for accurate coding and potential savings opportunities
• Review customer-submitted opportunities for complete and correct information
• Demonstrate knowledge of ICD-10-CM, PCS, and DRG coding, including payer rules and regulations such as Medicare and Medicaid
• Comply with internal and external policies
• Maintain working knowledge of HIPAA Privacy and Security Rules
• Assist the Quality Control team and medical director with appeals, rebuttals, and related tasks
• Notify leadership of issues or concerns promptly
• Perform additional duties as assigned

Knowledge and skills

• Expert knowledge of current Official Coding Guidelines and Coding Clinic citations
• Strong understanding of clinical criteria documentation requirements used to support code assignments
• Proficient understanding of Medicare, CMS, and ICD-10 coding guidelines
• Effective verbal and written communication skills
• Ability to work independently and in a team environment
• High attention to detail and strong critical thinking skills
• Ability to multitask and provide team coverage when needed
• Ability to build relationships internally and externally
• Ability to work in a fast-paced environment
• Proficiency with basic computer skills, typing, and Microsoft Office
• Familiarity with MS and APR DRG methodology preferred

Education and experience

• LVN or RN license in the state of employment preferred
• OR, ICU, or ER nursing experience preferred
• Minimum of 2 years of recent DRG quality auditing experience in a hospital setting or health plan required
• National coding certification required through AHIMA or AAPC
• Extensive hands-on ICD-10-CM/PCS experience required

Comprehensive benefits package for full-time regular employees, including:

• Medical (HDHP) with pharmacy
• Dental
• Vision
• Long-term disability
• Health savings account
• Flexible spending account options
• Life insurance
• Accident insurance
• Critical illness insurance
• Pre-paid legal insurance
• Parking and transit FSA accounts
• 401(k) and Roth 401(k)
• Paid time off