Clinical Review Auditor I

About the role

The Diagnostic Related Groups (DRG) Clinical Auditor will perform DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review.

Responsibilities

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Conduct audits to ensure accurate reimbursement and identify potential savings
• Demonstrate knowledge of ICD-10-CM codes, PCS, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid
• Understand and comply with all internal and external policies
• Work knowledge of HIPAA Privacy and Security Rules
• Aid Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of any issues or concerns in a timely manner

Requirements

• Strong written and verbal communication skills
• Knowledge of clinical knowledge of disease processes
• Knowledge of medical necessity rules

Qualifications

• LVN or RN license in the state of employment preferred
• CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS
• Experience in the OR, ICU, or ER as an RN highly preferred

Skills

• Proficient understanding of Medicare, CMS guidelines and ICD-10 coding guidelines
• Effective and professional communication skills, both verbal and written
• Ability to work independently and in a team environment
• High attention to detail
• Critical thinking skills
• Ability to multi-task and assist with team coverage and provide support when needed
• Ability to build relationships both internally and externally
• Ability to work in a fast-paced environment
• Proficiency with basic computer skills and typing
• Proficiency with Microsoft Office

Pay

Pay Range: $70,143 – $107,253

Schedule

Not specified