Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, focused on helping recovery, audit, and regulatory teams improve accuracy and reduce waste in healthcare payment integrity.
The DRG Validation Auditor reviews inpatient claims to ensure the DRG paid is fair and accurate based on medical record documentation and the application of ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, policies, and Coding Clinic advice. This role supports Penstock’s mission to improve integrity in payment accuracy, reduce unnecessary spend, and return dollars to payers while helping lower the cost of care.
Key responsibilities include:
- Reviewing healthcare claims and medical records to identify discrepancies between physician documentation, the clinical picture in the record, codes billed, and the resulting DRG
- Using industry references such as ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs, and AHA Coding Clinics
- Writing clear, complete, and accurate rationales supporting audit determinations
- Staying current on coding, clinical, regulatory, and industry changes that affect auditing and audit opportunities
- Developing new audit concepts and improving systems and processes involved with healthcare reimbursement
- Participating in training to expand auditing skills across multiple clinical and coding scenarios
- Communicating professionally with internal and external customers and escalating issues when needed
- Serving as a payment integrity subject matter expert for the Penstock team and Goodroot organization
- Meeting or exceeding performance and quality standards
Senior Auditor positions may provide support to the Team Lead as required.
Minimum qualifications:
- Associate degree
- Current AHIMA health information management credential: RHIT or RHIA
- Current AHIMA/AAPC coding credential: CCS or CIC
- Current clinical validation credential: CDIP, CCDS, or CDEI
- 3+ years of ICD-10 inpatient coding experience
- 1+ year of clinical experience in a healthcare facility setting
- 3+ years of auditing experience, or equivalent demonstrated experience
- 1+ year of auditing experience in a payor setting
- 1+ year of inpatient rehabilitation coding/auditing experience
- 1+ year of inpatient psychiatric coding/auditing experience
- Strong understanding of ICD-10-CM inpatient coding guidelines, AHA Coding Clinic, and DRG grouping mechanics
- Strong current clinical knowledge
- Familiarity with Clinical Documentation Integrity practices
- Knowledge of HIPAA and protections for PHI/PII
- Ability to conduct independent research using credible sources
- Working knowledge of Microsoft Word, Excel, and PowerPoint
- Strong critical thinking skills for record review
- Ability to work independently, manage workload, and adapt to shifting priorities
- Willingness to learn new auditing skills across a variety of coding and clinical scenarios
- Excellent oral and written communication skills
- Ability to work in a fast-paced, changing environment
- Ability to work Eastern time zone hours
- Secure, private home office with reliable high-speed internet
Preferred qualifications:
- Bachelor’s degree
- AHIMA/AAPC/ACDIS auditing credential or microcredential, such as AHIMA Inpatient Coding Microcredential or AAPC CPMA
- 5+ years of inpatient ICD-10 coding and auditing experience
- 5+ years of relevant auditing experience in clinical validation and medical necessity
- AHIMA/AAPC coding certifications such as RHIA, RHIT, CCS, CPC, or CPC-H
- AHIMA/ACDIS clinical documentation certification such as CDIP or CCDS, or related CDI experience
- 1-5 years of inpatient rehabilitation coding/auditing experience
- 1-5 years of inpatient psychiatric coding/auditing experience
Location
New York, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$85,000 - $95,000
Remote work allowed
Yes
Posted
1 week ago