Clinical DRG Auditor

Alaffia Health•New York, NY

7h•Remote

About The Position

Alaffia is seeking an experienced Clinical DRG Auditor to join our Payment Integrity team. In this role, you will perform inpatient Diagnosis-Related Group (DRG) validation audits and detailed clinical reviews of medical records and claims. You will leverage your clinical expertise and deep understanding of reimbursement, documentation standards, and coding guidelines to identify unsupported DRGs, improve payment accuracy, and inform audit automation. This role is ideal for an RN or LPN with hands-on experience in clinical DRG validation, inpatient auditing, or CDI-adjacent review work.

Requirements

Active Registered Nurse (RN) license or Licensed Practical Nurse (LPN) license.
3+ years of experience performing clinical DRG validation, inpatient clinical review, DRG auditing, CDI review, or similar payment integrity work.
Strong ability to interpret inpatient medical records and assess clinical validity of diagnoses and procedures.
Experience applying clinical judgment in a reimbursement or audit context.
Strong analytical and critical-thinking skills with exceptional attention to detail.
Clear written communication skills with the ability to articulate clinical rationale.
Ability to work independently in a remote environment and manage competing priorities.

Nice To Haves

Direct experience conducting DRG audits for payers, vendors, or consulting organizations.
Working knowledge of inpatient reimbursement methodologies and hospital billing workflows.
Familiarity with payer audit programs, pre-pay or post-pay reviews, and appeals support.
Experience working with audit platforms, EHRs, and claims data systems.
CPC, CCS, CIC, CPMA, CCDS, CDIP, or similar clinical/coding/audit certification.

Responsibilities

Perform comprehensive clinical DRG audits on inpatient claims, including validation of principal diagnosis, secondary diagnoses, CCs/MCCs, procedures, sequencing, and discharge status.
Evaluate whether clinical documentation supports the billed DRG in accordance with CMS guidelines, payer policies, and nationally accepted standards of care.
Apply clinical judgment and clinical guidelines to interpret complex inpatient medical records, including physician notes, labs, imaging, procedures, and treatment plans.
Identify documentation gaps, unsupported diagnoses, and DRG upcoding or misclassification.
Produce clear, defensible audit findings with concise clinical rationale.
Accurately document audit determinations in Alaffia’s audit platform and supporting tools.
Support quality assurance processes and peer review as needed.
Maintain working knowledge of ICD-10-CM/PCS coding principles, DRG groupers (MS-DRG, APR-DRG, AP-DRG as applicable), CMS guidance, and payer-specific reimbursement policies.
Ensure all audit activity complies with HIPAA, regulatory requirements, and internal SOPs.
Collaborate with payment integrity operations, product, and engineering teams to provide clinical insight that informs audit logic and AI-driven review models.
Contribute to ongoing process improvements, training, and audit optimization initiatives.