Clinical Review Auditor

TX - Fort Worth
5128 Apache Plume Rd
Suite 400
Fort Worth, TX 76109, USA

TX - Fort Worth
5128 Apache Plume Rd
Suite 400
Fort Worth, TX 76109, USA

The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding and clinically supported as defined by review methodologies specific to the type of review. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. Experience using ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures.

The ideal DRG Clinical Auditor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules.

This is a remote position.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and supporting clinical documentation
• Conducting audits to ensure accurate reimbursement and identifying potential savings
• Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid
• The ability to work independently with minimal supervision and demonstrate initiative
• Able to communicate clearly and accurately
• Clearly understands and comply with all internal and external policies
• Working knowledge of HIPAA Privacy and Security Rules
• Ability to multi-task and assist with team coverage and provide support when needed
• Ability to build relationships both internally and externally
• Assists Quality Control team and medical director with Appeals, Rebuttals, etc.
• Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc.
• Notify manager/leadership of any issues or concerns in a timely manner
• Additional duties as assigned by leadership

KNOWLEDGE & SKILLS:

• Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines
• 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 environment
• Proficient in Microsoft Office Suite

EDUCATION & EXPERIENCE:

• Current LVN or RN license in the state of employment.
• Current license must be maintained during employment
• CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS
• Experience in the OR, ICU, or ER as an RN highly preferred
• Must possess critical thinking skills

PAY RANGE:

Cor Vel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

ABOUT CERIS:

CERIS, a division of Cor Vel Corporation, a certified Great Place to Work Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities.

We embrace our core values of Accountability, Commitment, Excellence,…