Clinical Review QC Auditor

About the role

CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation.

Responsibilities

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Check for physician’s notes supporting the DRGs assigned
• Conduct audits to ensure accurate reimbursement and identifying potential savings
• Review previously conducted audits to ensure accurate coding and identifying potential savings
• Review all opportunities sent to the customers for complete and correct information
• Demonstrated 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 with Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of any issues or concerns in a timely manner

Requirements

• Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations
• Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments
• 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
• Must possess 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
• Demonstrated proficiency in basic computer skills and typing
• Proficiency with Microsoft Office
• Proficient in both MS and APR DRG methodology preferred

Qualifications

• LVN or RN license in the state of employment preferred
• Experience in the OR, ICU, or ER as an RN highly preferred
• Required minimum of 2 years of recent DRG Quality Auditing experience in a hospital setting, or health plan
• National Coding Certification required through either AHIMA (preferred) or AAPC
• Extensive hands-on ICD-10 CM / PCS experience required