Clinical Review QC Auditor

CorVel•Benbrook, TX

59d•$68,566 - $104,841•Remote

About The Position

CERiS in Fort Worth, Texas is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) QC Clinical Auditor will be responsible for performing quality control DRG validation (clinical/coding) reviews of internal audit team 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 records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination, as well as communicating missed or incorrect information to the auditors in a professional manner. Experience using, ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. This is a remote position. Job Duties and Responsibilities: The Quality Control Clinical Auditor will review previously audited claims for any missed opportunities or errors. The Quality Control Clinical Auditor will review all opportunities sent to the customers for complete and correct information. The Quality Control Clinical Auditor will check for physician's notes supporting the DRGs assigned. Reviewing medical records to determine accuracy of billing through verification of coding and supporting clinical documentation. Reviewing previously conducted audits to ensure accurate coding and identifying potential savings. Demonstrated expert knowledge of, ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative. Able to clearly, accurately, and professionally communicate coding/clinical information back to the Audit team or the customer, using correct grammar, spelling, sentence structure, and meet template format requirements.

Requirements

Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan.
National Coding Certification required through either AHIMA (preferred) or AAPC.
Extensive hands-on ICD-10 CM / PCS experience required.
Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations.
Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments.
Proficient in Medicare and CMS guidelines
Extreme attention to detail.
Must possess problem solving, critical thinking skills.
Minimal typing experience.
Effective and professional communication skills, both verbal and written.
Ability to think and work independently, while working in an overall team environment.
Ability to work in a fast paced/production environment.
Proficient in Microsoft Office Suite.
LVN or RN license in the state of employment preferred
CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS

Nice To Haves

RN license is preferred but not required.
Proficient in both MS and APR DRG methodology preferred.
Experience in the OR, ICU, or ER as an RN highly preferred

Responsibilities

The Quality Control Clinical Auditor will review previously audited claims for any missed opportunities or errors.
The Quality Control Clinical Auditor will review all opportunities sent to the customers for complete and correct information.
The Quality Control Clinical Auditor will check for physician's notes supporting the DRGs assigned.
Reviewing medical records to determine accuracy of billing through verification of coding and supporting clinical documentation.
Reviewing previously conducted audits to ensure accurate coding and identifying potential savings.
Able to clearly, accurately, and professionally communicate coding/clinical information back to the Audit team or the customer, using correct grammar, spelling, sentence structure, and meet template format requirements.