Auditor Clinical Validation DRG

Jobgether

2d • Remote

About The Position

This role focuses on auditing inpatient claims with a strong emphasis on clinical validation and coding accuracy. The Auditor Clinical Validation DRG is responsible for ensuring that medical records, billing, and coding practices comply with established guidelines and support appropriate reimbursement. You will analyze and review DRG/APR-DRG inpatient claims, integrating clinical expertise and advanced coding knowledge to assess the appropriateness of care and documentation. This position requires attention to detail, independent judgment, and the ability to identify opportunities for process improvement. The ideal candidate has a clinical background combined with hands-on coding and auditing experience, and thrives in a remote, structured, yet flexible environment. You will also leverage proprietary auditing tools to document findings and communicate results effectively.

Requirements

• Associate or bachelor’s degree in Nursing (active/unrestricted license), or Health Information Management (RHIA or RHIT), or equivalent experience with 5+ years in claims auditing, clinical validation, or recovery auditing.
• Required coding credentials: RHIA, RHIT, CPC, or inpatient coding certifications such as CCS, CIC, CDIP, or CCDS.
• 5–7+ years of experience with ICD-9/10-CM, MS-DRG, AP-DRG, APR-DRG, and medical claims billing/payment systems.
• Expertise in official coding guidelines, CMS compliance, and regulatory requirements.
• Strong proficiency in Word, Excel, Access, TEAMS, and other standard applications.
• Excellent written and verbal communication skills, with the ability to convey complex clinical and coding concepts clearly.
• Ability to work independently and maintain focus in a remote environment.
• Strong analytical skills, attention to detail, and commitment to accuracy and compliance.

Responsibilities

• Conduct comprehensive audits of inpatient claims, ensuring coding accuracy and clinical appropriateness.
• Integrate clinical knowledge with ICD-10, DRG, and APR-DRG coding standards to substantiate audit findings.
• Utilize proprietary auditing systems to perform audits, generate letters, and document results.
• Maintain productivity and accuracy standards set by the audit operations team.
• Identify new claim types or recovery opportunities beyond standard audit scopes.
• Suggest and implement process improvements, tools, and high-value concepts to enhance audit efficiency.
• Complete assigned projects, annual performance plan objectives, and ad hoc responsibilities while maintaining compliance with regulatory requirements.

Benefits

• Competitive base compensation at $45.67 per hour (annualized ~$95,000), with discretionary bonus eligibility.
• Overtime eligibility in accordance with state law for nonexempt employees.
• Comprehensive benefits package including medical, dental, vision, disability, and life insurance.
• 401(k) retirement savings plan.
• Paid family leave, 9 paid holidays, and 17–27 days of paid time off depending on tenure.
• Remote work with a dedicated home office and high-speed internet requirements supported.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree