The Clinical Auditor will conduct DRG validation reviews of medical records to determine the accuracy of billing and coding, verifying documentation to establish the correct DRG assignment. This involves accurately documenting findings and providing clinical, policy, or regulatory support for all determinations made during the review process.
Requirements summary
Candidates must possess experience with ICD-10-CM & PCS coding guidelines, modern pharmacology understanding, and knowledge of medical necessity rules, preferably holding an LVN or RN license and a required CCS or CIC certification with DRG auditing experience. Strong written and verbal communication skills, clinical knowledge of disease processes, and proficiency with basic computer skills are essential for success in this role.
professional certificateAttention To DetailCommunication SkillsPolicy ComplianceCritical ThinkingClinical KnowledgeHIPAAMedical Record ReviewMedicaidClinical ReviewDRG ValidationICD-10-CM CodingMedicare GuidelinesICD-10-PCS CodingQuality Control AssistanceMedical Necessity Rules
Job description
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
Knowledge & skills
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
Benefits
Accident Insurance
Critical Illness Insurance
Life Insurance
Medical
Dental
Vision
Paid Time Off
Health Savings Account
401K
Long Term Disability
Flexible Spending Account Options
ROTH 401K
Pre-paid Legal Insurance
Parking and Transit FSA accounts
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
Education & experience
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
Pay range
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.
For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.
Pay Range: $63,739 – $95,264
A list of our benefit offerings can be found on our CorVel website
In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.
About ceris
CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
