DRG​/Clinical Validation Auditor RN

Clinical DRG RN Auditor

In this position as a Clinical DRG RN auditor
, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify over payments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings.

• Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on over payment identification
• Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
• Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
• Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing
• Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
• Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
• Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
• Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements
• Maintain and manage daily case review assignments, with a high emphasis on quality
• Provide clinical support and expertise in the other investigative and analytical areas
• Work in a high-volume production environment that is matrix driven

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

• Associate's Degree (or higher)
• Unrestricted RN (Registered Nurse) license
• CCS/CIC or willing to obtain certification within 6 months of hire
• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
• 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
• 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers

• Experience with prior DRG concurrent and/or retrospective over payment identification audits
• Experience working with Utilization Management
• Experience with readmission reviews of claims
• Experience with DRG encoder tools (ex. 3M)
• Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
• Healthcare claims experience
• Managed care experience
• Knowledge of health insurance business, industry terminology, and regulatory guidelines

• Ability to use a Windows PC with the ability to utilize multiple applications at the same time
• Ability to work independently in a remote environment and deliver exceptional results
• Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail
• Excellent time management and work prioritization skills

• Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer
• Have a secluded office area in which to perform job duties during the work day
• Have reliable high-speed internet access and a work environment free from distractions

The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time…