Auditor, Quality Medical

About the role

This position performs validation reviews of Diagnosis Related Groups (DRG), Adaptive Predictive Coding (APC), and Never Events for all lines of business, coordinating rate adjustments with claims areas and providing monthly and quarterly trend reports.

Responsibilities

• Determines methodology to identify cases for validation review (75%)
• Conducts validation reviews and coordinates rate adjustments with appropriate claims area (75%)
• Creates monthly and quarterly reports for each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates (75%)
• Manages records retrieval, release, HIPAA compliance, and all aspects of document management (15%)
• Serves as expert resource on methodology and procedures for medical records and coding issues (10%)
• Serves as a resource in resolving coding issues
• Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department

Requirements

• Registered Records Administrator or Technician (RHIT or RHIA)
• OR active, unrestricted RN licensure from the United States and in the state of hire
• OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• OR Certified Coder (CPC, CIC, or CPMA)

Skills

• Develops methodologies
• Follows processes
• Responds to inquiries
• Writes for impact

Schedule

Monday–Friday, 8:00 AM – 4:30 PM. Fully remote position with client-provided equipment. Candidates from SC or NC preferred, though other regions may be considered.

Interview process

Two interviews: first round via Teams, second round onsite with manager and coder.