Nurse Coder, DRG Auditor III

This is a fully remote position, open to applicants in United States.

📋 Description

• Serve as a Subject Matter Expert.

• Conduct independent audits of outpatient and inpatient claims in accordance with coding guidelines and relevant medical documentation.

• Prepare appeal responses and communicate findings effectively.

• Validate and execute quality checks for fellow team members independently.

• Exercise strategic decision-making authority.

• Provide management with recommendations at the enterprise level.

• Employ coding and clinical guidelines for DRG or APC validation.

• Confirm principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses, and procedures by reviewing medical records.

• Assess short-stay claims for the medical necessity of inpatient-level care.

• Utilize CPT and ICD-10 guidelines.

• Implement policies, procedures, guidelines, and regulations from CMS, commercial payers, InterQual, MCG, and TREND Health Partners.

• Aid in the development of new concepts and criteria for claim selection.

• Assist with itemized bill reviews as necessary.

• Maintain required licensures, certifications, and continuing education obligations.

• Communicate with clients as needed to support findings.

• Independently apply and establish coding guidelines for others.

• Conduct quality checks for team members.

• Undertake other assigned duties.

⛳️ Requirements

• An active RN professional license in good standing.

• Experience in clinical practice.

• Coding certification in good standing, such as CCS or CIC.

• Experience in coding validation and auditing.

• Strong verbal and written communication skills, along with excellent organizational abilities.

• Capability to prioritize tasks effectively.

• Proficiency in Microsoft Office, particularly Excel.

• Employees may need to undergo background and drug screenings and disclose personal health information or personally identifiable information for Business Partners.

• Reasonable accommodations may be provided for individuals with disabilities.

🏝️ Benefits

• Competitive salaries.

• Health insurance.

• 401(k) plan with employer match.

• Paid parental leave.

• Collaborative and innovative work environment.