DRG Auditor

Senior Clinical DRG Auditor (Remote)

Excellent opportunity for an experienced Registered Nurse with DRG auditing and coding expertise who enjoys analyzing complex medical records, applying critical thinking skills, and working in a collaborative remote environment.

We are seeking an experienced Senior Clinical DRG Auditor to perform comprehensive reviews of inpatient medical records to validate diagnosis and procedure coding accuracy, clinical documentation integrity, and DRG assignment. This role combines advanced clinical knowledge, ICD-10 coding expertise, and reimbursement methodology understanding to ensure accurate coding and payment determinations.

The ideal candidate will possess strong inpatient clinical experience, extensive DRG auditing expertise, and the ability to independently evaluate complex medical documentation.

Responsibilities

• Conduct detailed reviews of inpatient medical records to validate diagnosis, procedure, and DRG assignments.
• Evaluate principal and secondary diagnoses, including CCs and MCCs, to ensure documentation supports code selection.
• Apply ICD-10-CM, ICD-10-PCS, CMS guidelines, Coding Clinic guidance, and payer-specific policies when making audit determinations.
• Assess medical necessity and clinical documentation to support coding accuracy and reimbursement methodologies.
• Document audit findings, rationale, and recommendations within internal systems.
• Maintain established productivity and quality standards.
• Collaborate with clinical, coding, and audit team members to ensure consistency in review methodologies.
• Provide mentorship, guidance, and education to less experienced auditors and coding professionals.
• Stay current on regulatory changes, coding updates, industry best practices, and reimbursement guidelines.

Qualifications

Required

• Active, unrestricted Compact Registered Nurse (RN) license.
• One of the following certifications:
• RHIA (Registered Health Information Administrator)
• RHIT (Registered Health Information Technician)
• CCS (Certified Coding Specialist)
• CIC (Certified Inpatient Coder)
• CCDS (Certified Clinical Documentation Specialist)
• CPC (Certified Professional Coder)
• Minimum 3 years of inpatient acute care clinical experience.
• Minimum 2 years of experience in DRG auditing, DRG validation, inpatient coding, CDI, or a related specialty.
• Advanced knowledge of:
• MS-DRG and APR-DRG methodologies
• ICD-10-CM coding guidelines
• ICD-10-PCS coding and sequencing
• Severity of Illness (SOI) and Risk of Mortality (ROM)
• CMS reimbursement and documentation standards
• InterQual and/or Milliman guidelines
• Strong analytical, critical thinking, and clinical decision-making skills.
• Proficiency with Microsoft Office applications and virtual collaboration tools.

Preferred

• Experience auditing complex inpatient cases across multiple service lines.
• Knowledge of payer-specific DRG validation and reimbursement practices.
• Prior experience mentoring or training coding and audit professionals.

Benefits Featured

Medical, Dental , and Vision Insurance is offered to qualified candidates.