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Clinical DRG Auditor

Date:  Jan 5, 2022

Any city, TX, US, 99999

Req ID:  7286


We are seeking a talented individual for a Clinical DRG Auditor who is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to validate the conditions that were documented in the medical record, the ICD-10-CM/PCS code assignments and determine the accuracy of DRG assignment that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided.  This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. The candidate must have extensive clinical experience with a background in auditing medical records with a high level of understanding payment methodologies including MS-DRG, AP-DRG and APR-DRG.

Job Description

Essential Responsibilities:

  • Performs audits of medical record documentation to determine the accuracy of principal and secondary diagnosis (including MCC & CC) and procedure codes. Adheres to official coding guidelines, coding clinics and regulatory guidelines and mandates. Draws on advanced ICD-10 coding expertise and clinical knowledge to substantiate conclusions. Utilizes HMS proprietary auditing systems with a high level of proficiency to document audit determinations and rationale. Applies critical clinical review judgment to make coding validation determinations including sequencing ICD-10-CM, ICD-10-PCS procedural codes for inpatient claims.
  • Consistently achieves productivity and quality performance standards established by management.
  • Assists management with training new Coders or Clinical DRG Auditors to include daily monitoring, mentoring, feedback and education.
  • Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain RN license and coding certification
  • Responsible for attending training and scheduled meetings to enhance skills and working  knowledge of clinical policies, procedures, rules, and regulations.
  • Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
  • Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction

Non-Essential Responsibilities:

  • Performs other functions as assigned

Job Description

Knowledge, Skills and Abilities:

  • Demonstrated proficiency in medical record auditing and ICD-10-CM and ICD-10-PCS coding methodologies, code sequencing, and discharge disposition in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.
  • Demonstrated knowledge of medical codes, coding conventions and rules.
  • Demonstrated experience in medical review, chart audits, and quality improvement processes.
  • Demonstrates a thorough understanding of the APR-DRG, AP-DRG, MS-DRG, ICD-10, clinical criteria, and clinical review judgement
  • Demonstrated experience with coding systems and grouper applications.
  • Demonstrated ability to apply clinical review judgment to make clinical determinations
  • Demonstrated ability to write clear, accurate, concise rationales in support of findings.
  • Working knowledge of HIPAA Privacy and Security Rules.
  • Ability to multi-task in a fast paced working environment.
  • Ability to work in a production environment
  • Ability to build relationships both internally and externally.
  • Demonstrated proficiency in computer skills and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.
  • Demonstrated proficiency in virtual meeting tools i.e., Microsoft Teams, Zoom, etc.

Work Conditions and Physical Demands:

  • Home based position and you must have a work location within the continental US
  • This position requires that you provide high speed internet connection and a work environment free from distractions
  • Ability to work during business hours as this position requires frequent interactions with the team and other departments within HMS
  • Primarily sedentary work in a general office environment
  • Ability to communicate and exchange information
  • Ability to comprehend and interpret documents and data
  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
  • Requires manual dexterity to use computer, telephone and peripherals
  • May be required to work extended hours for special business needs
  • May be required to travel at least 10% of time based on business needs


Minimum Education:

  • Bachelor's degree in Nursing preferred.

Certifications (Required/Desired):

  • Active and unrestricted RN license required;
  • Coding credential required within 1 year in position -  CCS (Certified Coding Specialist) or CIC (Certified Inpatient Coder) or CPC (Certified Professional Coder) or Clinical Documentation Improvement (CDI) or Certified Clinical Documentation Specialist (CCDS)

Minimum Related Work Experience:

  • 5+ years clinical experience in an inpatient hospital setting required
  • 2+ years claims auditing experience required

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