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Clinical Review Auditor
CLINI011061 The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing 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. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES:
- The Clinical Auditor will 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 identifying potential savings
- 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
- Working knowledge of HIPAA Privacy and Security Rules
- Assist Quality Control team and medical director with appeals, rebuttals, etc.
- Notify leadership of any issues or concerns in a timely manner
- Additional duties as assigned
- 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
- 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
