Senior Auditor Quality - DRG

Responsibilities

• Performs clinical quality assurance review of daily clinical validation reviews.
• Communicates with the initial auditor when there are differing decisions on the audit to ensure the final decision is supported and as accurate as possible.
• Integrates healthcare auditing principles and uses objectivity in performance of medical audit activities and review.
• Utilizes industry knowledge and proficiency in healthcare to substantiate decisions.
• Performs work independently and reviews work of others.
• Depending on the nature and scope of audit, may review medical records and apply in-depth knowledge of clinical criteria to determine medical necessity, appropriateness of setting, potential billing/coding issues, and quality concerns.
• May serve as a mentor to other QA auditors or initial auditors.
• Depending on the business needs, may also flex into the initial audit role and/or the appeals role as needed.

Qualifications

• (At least one of the following are required): Associates or Bachelor's degree in Nursing (active / unrestricted license), Associates or Bachelor's degree Health Information Management (RHIA or RHIT), Equivalent experience of 5+ years experience in claims auditing, quality assurance, or recovery auditing—ideally in a DRG / Clinical Validation Audit setting or a hospital environment.
• Coding Certification (at least one of the following are required and are to be maintained as a condition of employment): RHIA or RHIT, Inpatient Coding Credential - CCS or CIC preferred, or Candidates who hold a CCDS or CPC will be given consideration but will need to obtain an inpatient coding certification within 1 year of their hire date with the company.
• 3-5 years of healthcare auditing or related experience.
• Ability to mentor staff and enhance performance as it relates to the quality and productivity of auditors.
• Excellent verbal and written communication skills.
• Ability to work well in an individual and team environment.
• Computer proficiency in Microsoft office suite required (Excel, Outlook, PowerPoint, SharePoint, etc.).