Accountabilities:

The Auditor Clinical Validation DRG is responsible for performing detailed inpatient claim audits with a focus on clinical accuracy, coding compliance, and reimbursement integrity.

• Conduct comprehensive inpatient claims audits using clinical records, coding guidelines, and regulatory standards to validate DRG/APR-DRG assignments.
• Apply advanced ICD-10, MS-DRG, APR-DRG, and related coding knowledge to support audit findings and ensure compliance with payer and CMS guidelines.
• Utilize proprietary audit systems and tools to document findings, generate audit determinations, and prepare formal audit correspondence.
• Maintain required productivity levels while ensuring accuracy, quality, and adherence to audit standards.
• Identify claims outside of standard audit scope that may present additional recovery opportunities or risk areas.
• Contribute to continuous improvement efforts by suggesting enhancements to audit tools, methodologies, and workflows.
• Complete assigned responsibilities, special projects, and performance objectives in alignment with organizational expectations.

Requirements:

This role requires strong clinical and coding expertise combined with experience in healthcare auditing, claims validation, or revenue integrity environments. Candidates must be highly detail-oriented and comfortable working independently in a structured, compliance-focused setting.

• Associate or bachelor’s degree in Nursing (active, unrestricted license) OR Health Information Management (RHIA/RHIT) OR equivalent experience with high school diploma/GED and 5+ years in auditing or healthcare claims.
• One or more active certifications required: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.
• 5–7+ years of experience working with ICD-9/10, MS-DRG, APR-DRG, and inpatient coding and billing systems.
• Strong knowledge of medical necessity criteria, payer reimbursement rules, and regulatory compliance standards (CMS and coding clinic guidance).
• Proficiency with standard office tools such as Word, Excel, Access, and collaboration platforms like Microsoft Teams.
• Strong analytical thinking, attention to detail, and ability to assess complex medical documentation accurately.
• Excellent written and verbal communication skills for audit documentation and findings.
• Ability to work independently in a remote environment with a secure, dedicated workspace and reliable high-speed internet.

Benefits:

• Competitive hourly compensation (approximately $45.67/hour, annualized around $95K)
• Eligibility for discretionary performance bonus
• Comprehensive medical, dental, vision, life, and disability insurance coverage
• 401(k) retirement savings plan
• Paid family leave and paid holidays (9 per year)
• Generous PTO allowance (17–27 days depending on tenure and level)
• Fully remote work arrangement with flexible home-office setup requirements
• Opportunity to work on high-impact healthcare audit and compliance initiatives