Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG

This is a fully remote position, open to applicants in California, +7 more states.

📋 Description

• Conduct audits of inpatient medical records to verify that clinical documentation aligns with billed conditions and DRGs.

• Examine Diagnosis Related Group (DRG) paid claims.

• Evaluate and audit claims utilizing medical chart coding principles, clinical guidelines, and objective audit practices.

• Leverage advanced ICD-10 coding expertise and clinical guidelines to validate audit conclusions.

• Employ audit tools, workflow systems, and reference materials to produce audit determinations and comprehensive audit findings letters.

• Uphold accuracy and quality standards set by audit management.

• Detect documentation and coding discrepancies and unusual patterns, including improper readmissions, inpatient admission status, and Hospital-Acquired Conditions.

• Propose and create concepts for process improvements and efficiency enhancements.

⛳️ Requirements

• A current, active, unrestricted Registered Nurse license in the applicable state(s) is required.

• A minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement.

• At least 5 years of experience with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG.

• An educational and experiential background that together may be considered equivalent is acceptable.

• Preferred certifications include RHIT, RHIA, CCDS, CDIP, CPC, CCS, or CIC.

• Experience with third-party DRG coding and/or clinical validation audits or hospital clinical documentation improvement is preferred.

• A thorough understanding of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology is preferred.

🏝️ Benefits

• Comprehensive benefits package.

• Incentive and recognition programs.

• Equity stock purchase options.

• 401k contributions.

• Merit-based salary increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) with employer match.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.