Clinical Review Auditor

Accountabilities: Review medical records and supporting documentation to validate DRG assignments and ensure billing accuracy. Conduct clinical and coding audits to identify discrepancies, reimbursement opportunities, and potential cost savings. Apply ICD-10-CM, ICD-10-PCS, and DRG review methodologies to determine appropriate coding and documentation standards. Evaluate clinical documentation and provide evidence-based support for findings, recommendations, and determinations. Ensure compliance with payer requirements, Medicare and Medicaid regulations, and applicable internal policies and procedures. Maintain working knowledge of HIPAA Privacy and Security requirements and ensure confidentiality of sensitive information. Collaborate with quality assurance teams and medical leadership on appeals, rebuttals, and complex review cases. Accurately document audit findings, communicate concerns promptly, and escalate issues to leadership when necessary. Provide support across the team as needed and contribute to continuous process improvement initiatives. Requirements: Required certification as a Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC), with demonstrated DRG auditing experience. Strong experience with ICD-10-CM and ICD-10-PCS coding guidelines and methodologies. Licensed Vocational Nurse (LVN) or Registered Nurse (RN) credentials are preferred. Previous clinical experience in Operating Room (OR), Intensive Care Unit (ICU), or Emergency Room (ER) settings is highly preferred. Strong understanding of Medicare, CMS guidelines, payer regulations, and medical necessity requirements. Excellent analytical and critical thinking skills with the ability to assess complex clinical documentation. High level of attention to detail and ability to maintain accuracy in a fast-paced environment. Strong written and verbal communication skills with the ability to effectively explain audit findings and recommendations. Ability to work independently while also collaborating effectively within cross-functional teams. Strong organizational skills with the ability to manage multiple priorities and provide team support when needed. Proficiency with Microsoft Office applications and general computer systems. Benefits: Competitive salary range of $70,143–$107,253 USD , depending on location, experience, qualifications, and market conditions. Fully remote work environment offering flexibility and work-life balance. Comprehensive medical, dental, and vision insurance coverage. Pharmacy benefits and health savings account options. Flexible spending accounts for healthcare, dependent care, parking, and transit expenses. Long-term disability, life insurance, accident insurance, and critical illness coverage. Pre-paid legal insurance benefits. 401(k) and Roth 401(k) retirement savings plans. Paid time off and comprehensive employee wellness support. Opportunities for professional growth, continued learning, and career advancement within a stable and expanding organization.