Clinical Review QC Auditor

Job Description

CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. 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.

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Check for physician's notes supporting the DRGs assigned
• Conduct audits to ensure accurate reimbursement and identifying potential savings
• Review previously conducted audits to ensure accurate coding and identifying potential savings
• Review all opportunities sent to the customers for complete and correct information
• 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

• Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations
• Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments
• 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
• 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
• Proficient in both MS and APR DRG methodology preferred

• LVN or RN license in the state of employment preferred
• Experience in the OR, ICU, or ER as an RN highly preferred
• Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan. National Coding Certification required through either AHIMA (preferred) or AAPC
• Extensive hands‑on ICD-10 CM / PCS experience required

Cor Vel 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: $68,566 – $104,841

A list of our benefit offerings can be found on our Cor Vel website:
Cor Vel Careers | Opportunities in Risk Management

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.

CERIS,…