Diagnosis Related Group Clinical Validation Auditor-RN

About This Role

The Diagnosis Related Group Clinical Validation Auditor-RN ensures clinical documentation supports the conditions and DRGs billed and reimbursed by auditing inpatient medical records. This role specializes in reviewing DRG paid claims.

Responsibilities

• Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in medical audit activities
• Utilize advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions
• Utilize audit tools, auditing workflow systems, and reference information to generate audit determinations and formulate detailed audit findings letters
• Maintain accuracy and quality standards as established by audit management
• Identify potential documentation and coding errors by recognizing aberrant coding and documentation patterns
• Suggest and develop high quality, high value, concept and process improvement and efficiency recommendations

Requirements

• Current, active, unrestricted Registered Nurse license in applicable state(s)
• Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement
• Minimum of 5 years of experience working with ICD-9/10CM
• Minimum of 5 years of experience working with MS-DRG
• Minimum of 5 years of experience working with AP-DRG
• Minimum of 5 years of experience working with APR-DRG

Qualifications

• A minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG, or equivalent.

Nice to Have

• Registered Health Information Technician (RHIT) certification
• Registered Health Information Administrator (RHIA) certification
• Certified Clinical Documentation Specialist (CCDS) certification
• Certified Documentation Improvement Practitioner (CDIP) certification
• Certified Professional Coder (CPC) certification
• Inpatient Coding Credential such as CCS or CIC
• Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement
• Broad knowledge of clinical documentation improvement guidelines
• Broad knowledge of medical claims billing and payment systems
• Broad knowledge of provider billing guidelines
• Broad knowledge of payer reimbursement policies and coding terminology

Skills

* Required skills

Benefits