DRG Validation Auditor: Full-time Remote

Penstock Grp. • Williamsville, NY

2d • $85,000 - $95,000 • Remote

About The Position

The DRG Validation Auditor is a member of Penstock’s audit team who reviews inpatient claims and medical records to determine whether the paid DRG is fair and accurate based on documentation and applicable ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, policies, and Coding Clinic advice. The role upholds Penstock’s standards of honesty, excellence, and innovation.

The auditor identifies discrepancies among physician documentation, the clinical picture in the medical record, billed codes, and the resulting DRG. They support audit findings with industry-recognized references and write clear, complete rationales citing the record and relevant guidelines, policies, regulations, or coding advice. The role also monitors industry changes and develops audit concepts, communicates process-improvement ideas, participates in training, and works professionally with internal and external customers.

The position contributes to Penstock’s payment-integrity mission and serves as a subject matter expert for Penstock and the broader Goodroot organization. Auditors are expected to meet or exceed performance and quality standards. Senior Auditor positions provide support to the Team Lead as required.

Requirements

• Minimum of an associate degree.
• Current AHIMA Health Information Management credential: RHIT or RHIA.
• Current AHIMA/AAPC coding credential: CCS or CIC.
• Current clinical validation credential: CDIP, CCDS, or CDEI.
• At least 3 years of ICD-10 inpatient coding experience.
• At least 1 year of clinical experience in a healthcare facility setting.
• At least 3 years of auditing experience, or demonstrated equivalent.
• At least 1 year of auditing experience in a payor setting.
• At least 1 year of Inpatient Rehabilitation coding or auditing experience.
• At least 1 year of Inpatient Psychiatric coding or auditing experience.
• Comprehensive understanding of ICD-10-CM Inpatient Coding Guidelines, AHA Coding Clinic, and DRG grouping mechanics.
• Strong current clinical knowledgebase.
• Familiarity with Clinical Documentation Integrity practices.
• Awareness of and adherence to HIPAA and laws governing the safeguarding of PHI/PII.
• Ability to conduct independent research using credible sources.
• Working knowledge of Microsoft Word, Excel, and PowerPoint.
• Ability to apply critical thinking to record reviews.
• Ability to work independently, manage workload, and adapt to shifting priorities.
• Willingness to adapt and learn auditing skills across coding and clinical scenarios.
• Excellent oral and written communication skills.
• Comfort working in a fast-paced, ever-changing environment.
• Ability to work Eastern time zone hours.
• Secure, private home office with reliable high-speed internet connection.

Nice To Haves

• Bachelor’s degree.
• AHIMA/AAPC/ACDIS auditing credential, such as the AHIMA Inpatient Coding Microcredential or AAPC Certified Professional Medical Auditor (CPMA).
• At least 5 years of inpatient ICD-10 coding and auditing experience.
• At least 5 years of relevant auditing experience in clinical validation and medical necessity.
• AHIMA/AAPC coding certifications such as RHIA, RHIT, CCS, CPC, or CPC-H; AHIMA/ACDIS clinical documentation certification such as CDIP or CCDS; or Clinical Documentation Integrity experience.
• 1–5 years of Inpatient Rehabilitation coding or auditing experience.
• 1–5 years of Inpatient Psychiatric coding or auditing experience.

Responsibilities

• Review healthcare claims and medical records to identify discrepancies between physician documentation, the clinical picture, billed codes, and the resulting DRG.
• Use recognized references to support findings, including ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs on compliant querying, and AHA Coding Clinics.
• Write complete, clear, and accurate rationales for audit determinations, citing information from the record and relevant guidelines, policies, regulations, or coding advice.
• Keep abreast of coding, clinical, regulatory, and other industry changes that affect auditing or may suggest new audit opportunities.
• Help identify and develop new audit concepts.
• Consider healthcare reimbursement systems and processes and communicate ideas for improvement through appropriate channels.
• Participate in focused training to develop auditing skills across clinical and coding scenarios.
• Communicate kindly, professionally, and effectively with internal and external customers, referring issues to management as appropriate.
• Pursue new ways to advance Penstock’s mission of improving integrity between payors and providers.
• Serve as a Payment Integrity subject matter expert for Penstock team members and the Goodroot organization.
• Meet or exceed Penstock’s performance and quality standards.
• For Senior Auditor positions, provide support for the Team Lead as required.

Benefits

• Annual bonus based on salary and additional compensation for audits completed beyond weekly production expectations.
• Medical and dental coverage with employer contributions, plus fully paid vision insurance.
• Fully paid short-term and long-term disability coverage and company-paid life insurance with coverage up to $1 million.
• Flexible PTO and company-wide Wellbeing Days.
• Access to coding and clinical reference resources, including 12+ free CEUs annually.
• Payment of annual maintenance fees for two professional credentials.
• Ancillary benefit options and an employee referral program.

What This Job Offers

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