Job Summary:

The DRG Chart Auditor is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical review forms, accurately documenting findings, and providing clinical/policy/regulatory support for determination.

Essential Duties and Responsibilities:

• Prepare convincing arguments to provider or payer reconsiderations using pre-existing criteria and/or clinical evidence.
• Provide detailed and easily understandable rationale and supporting evidence for recommendation and findings.
• Responsible for auditing documentation to support coding and billing regulations to ensure reimbursement accuracy.
• Collaborate with Coding and Clinical Lead to ensure DRG denial is thoroughly reviewed.
• Review patient medical records and utilize clinical and regulatory knowledge and skills along with payer requirements.
• Perform all audits in observance of organizational quality standards.
• Maintains production goals set by the audit operations management team.
• Utilizes CLQ proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
• Makes recommendations for improvements to the audit system that enhance efficiency.
• Other duties as assigned.

Education (required)

• Associates or Bachelor's degree in Nursing (active/unrestricted license)
• Equivalent experience of 2+ years’ experience in inpatient claims auditing, quality assurance, or recovery auditing

Coding Certification (at least one of the following are desired)

• RHIA - Registered Health Information Administrator + CCS or CIC/CPC-H, or
• RHIT- Registered Health Information Technician + CCS or CIC/CPC-H, or
• CCS - Certified Coding Specialist, or
• CPC-H, Certified Professional Coder-H (Hospital Based), or
• CIC, Certified Inpatient Coder

Experience

• Demonstrates ability to work efficiently and effectively with minimal direct supervision
• Exhibits high standards of quality and attention to detail
• Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
• Demonstrates superior knowledge of healthcare coding, billing and reimbursement
• Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations.
• Working knowledge of DRG clinical claim review
• Solid knowledge and understanding of clinical criteria documentation requirements to successfully substantiate code assignments
• Demonstrated understanding of the APR-DRG, MS-DRG, ICD-10, clinical criteria, and clinical review judgement
• Demonstrated proficiency in medical record analysis and ICD-10-CM and PCS coding methodologies.
• Demonstrated knowledge of medical codes, coding conventions and rules.

Computer Equipment and Software

• Experience working with multiple monitors
• Experience working remotely
• Working knowledge of Windows office systems including full Microsoft Suite and Teams
• Advanced software skills in Microsoft Office (Excel)
• Experience with various forms of software and experience engaging development teams
• Experience with Encoder programs and/or similar coding and auditing tools

Physical Demands

• Requires the ability to sit or stand for long periods of time, occasional stooping, and reaching; May require lifting up to 25 pounds; Requires a normal range of vision and hearing with or without accommodations; Position is not substantially exposed to adverse environmental conditions