RN Auditor

Job Title: DRG Validation RN Auditor

Job Type: Contract to Hire

Location: Remote/Telecommute (No specific time zone required; lunch breaks provided)

Hours: 40 hours/weekly (Day schedules, anytime between 7am to 6pm EST)

Rate: $35/hour

Position Overview:

As a DRG Validation RN Auditor, you will leverage your expertise in MS-DRG and APR-DRG coding/reimbursement methodologies, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines to audit inpatient claims. Using 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 overpayments. Your excellent communication skills will be essential in composing rationales to support your audit findings.

Primary Responsibilities:

• Conduct MS-DRG and APR-DRG coding reviews to verify DRG assignment and reimbursement accuracy, focusing on overpayment identification.
• Identify ICD-10-CM/PCS code assignments, appropriate code sequencing, POA assignment, and discharge disposition per CMS requirements, ICD-10 Official Guidelines, and AHA Coding Clinic guidance.
• Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations, demonstrating knowledge of clinical criteria documentation requirements.
• Perform clinical coding reviews to ensure medical coding accuracy, using clinical expertise and judgment.
• Maintain a solid command of anatomy and physiology, diagnostic procedures, and surgical operations, developed through specialized training and extensive ICD-10-PCS code assignment experience.
• Write clear, accurate, and concise rationales supporting findings using ICD-10 CM/PCS Official Coding Guidelines and AHA Coding Clinics.
• Utilize proprietary workflow systems and encoder tools efficiently to make audit determinations, generate audit rationales, and move claims through the workflow process correctly.
• Stay updated on coding guidelines, reimbursement trends, and client processes and requirements.
• Manage daily case review assignments with a high emphasis on quality.
• Provide clinical support and expertise to other investigative and analytical areas.
• Work in a high-volume production environment that is matrix-driven.

Required Qualifications:

• Unrestricted RN license (registered nurse)
• CCS/CIC certification or ability to obtain 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
• Expert knowledge of ICD-10-CM coding, including principal diagnosis selection, CCs/MCCs, and conditions impacting SOI and ROM
• Expert knowledge of ICD-10-PCS coding, including selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers

Preferred Qualifications:

• Experience with prior DRG concurrent and/or retrospective overpayment identification audits
• Experience with readmission reviews of claims
• Experience with DRG encoder tools (e.g., 3M)
• Proficiency in Microsoft Excel for creating/editing spreadsheets, using sort/filter functions, and performing data entry
• Healthcare claims experience
• Managed care experience
• Knowledge of health insurance business, industry terminology, and regulatory guidelines

Soft Skills:

• Ability to use a Windows PC and multiple applications simultaneously
• Excellent written and verbal communication skills, strong analytical skills, and attention to detail
• Ability to work independently in a remote environment and deliver exceptional results
• Excellent time management and work prioritization skills

Physical Requirements and Work Environment:

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

How to Apply: