Auditor Clinical Validation DRG
Accountabilities: The Auditor Clinical Validation DRG is responsible for performing detailed inpatient claim audits with a focus on clinical accuracy, coding compliance, and reimbursement integrity.
Conduct comprehensive inpatient claims audits using clinical records, coding guidelines, and regulatory standards to validate DRG/APR-DRG assignments.
Apply advanced ICD-10, MS-DRG, APR-DRG, and related coding knowledge to support audit findings and ensure compliance with payer and CMS guidelines.
Utilize proprietary audit systems and tools to document findings, generate audit determinations, and prepare formal audit correspondence.
Maintain required productivity levels while ensuring accuracy, quality, and adherence to audit standards.
Identify claims outside of standard audit scope that may present additional recovery opportunities or risk areas.
Contribute to continuous improvement efforts by suggesting enhancements to audit tools, methodologies, and workflows.
Complete assigned responsibilities, special projects, and performance objectives in alignment with organizational expectations.
Requirements:
This role requires strong clinical and coding expertise combined with experience in healthcare auditing, claims validation, or revenue integrity environments. Candidates must be highly detail-oriented and comfortable working independently in a structured, compliance-focused setting.
Associate or bachelor’s degree in Nursing (active, unrestricted license) OR Health Information Management (RHIA/RHIT) OR equivalent experience with high school diploma/GED and 5+ years in auditing or healthcare claims.
One or more active certifications required: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.
5–7+ years of experience working with ICD-9/10, MS-DRG, APR-DRG, and inpatient coding and billing systems.
Strong knowledge of medical necessity criteria, payer reimbursement rules, and regulatory compliance standards (CMS and coding clinic guidance).
Proficiency with standard office tools such as Word, Excel, Access, and collaboration platforms like Microsoft Teams.
Strong analytical thinking, attention to detail, and ability to assess complex medical documentation accurately.
Excellent written and verbal communication skills for audit documentation and findings.
Ability to work independently in a remote environment with a secure, dedicated workspace and reliable high-speed internet.
Benefits:
Competitive hourly compensation (approximately $45.67/hour, annualized around $95K)
Eligibility for discretionary performance bonus
Comprehensive medical, dental, vision, life, and disability insurance coverage
401(k) retirement savings plan
Paid family leave and paid holidays (9 per year)
Generous PTO allowance (17–27 days depending on tenure and level)
Fully remote work arrangement with flexible home-office setup requirements
Opportunity to work on high-impact healthcare audit and compliance initiatives
How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether?
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