Clinical DRG Auditor

Alaffia Health; United States; À distance; USD 90 000 - 120 000; Plein temps

Avantages offerts par ce poste

401(k)

Medical, Dental, Vision benefits

Flexible paid vacation

Direct access to Leadership

Résumé du poste

Alaffia Health is seeking an experienced Clinical DRG Auditor to join our Payment Integrity team. In this role, you will perform inpatient DRG validation audits and clinical reviews of medical records and claims, leveraging your clinical expertise to identify unsupported DRGs and improve payment accuracy.

This position is ideal for an RN or LPN with hands-on experience in DRG validation, inpatient auditing, or CDI-adjacent review work.

Qualifications

• Active RN license required.
• 3+ years of experience in 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/procedures.
• Experience applying clinical judgment in reimbursement or audit context.

Responsabilités

• Perform clinical DRG audits on inpatient claims, validating diagnoses, CCs/MCCs, procedures, and discharge status.
• Evaluate whether documentation supports the billed DRG per CMS guidelines and payer policies.
• Apply clinical judgment to interpret complex inpatient records including physician notes, labs, imaging, and treatments.
• Identify documentation gaps and potential DRG upcoding or misclassification.

Connaissances

RN license

3+ years experience

Inpatient DRG validation

Clinical documentation interpretation

Outils

Audit platforms

EHR systems

Claims data systems

Description du poste

Every year, U.S. health plans lose billions to improper payments and administrative waste. That wasted spending ultimately trickles down across the healthcare ecosystem, driving up costs for plans, providers, and patients alike. We’re here to change that paradigm.

Alaffia is a new kind of claims operations partner for health plans. Using expert clinicians and transparent AI, we deliver deeper insights, smarter automation, and consistently better outcomes across the entire lifecycle of claims. With Alaffia, health plans can cut wasted spending more effectively than ever — and provide their members the most affordable care.

We’re a high-growth, venture-backed Series B healthtech startup based in NYC and are actively scaling our company. Join us in helping to build a healthcare system that works better for everyone.

*This position requires current authorization to work in the United States. Unfortunately, we are not in a position to sponsor work visas at this time.

About the Role

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.

What You’ll be Doing

Clinical DRG Review & Validation

• 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.

Audit Documentation & Reporting

• 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.

Compliance & Policy Adherence

• 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.

Cross-Functional Collaboration

• 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.

Who You Are

Required Qualifications

• Active Registered Nurse (RN) 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.

Preferred Qualifications

• 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.

Certifications (Preferred, Not Required)

• CPC, CCS, CIC, CPMA, CCDS, CDIP, or similar clinical/coding/audit certification.

Core Competencies

• 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.

Our Culture

Alaffia was born out of our founders’ personal connection to the inefficiency of the U.S. healthcare system. We are deeply mission-driven, with an abiding belief that technology can help create a better future for everyone — and we’re looking for others who share our passion for change to join the team.

What Else Do You Get Working With Us?

401(k), Medical, Dental, and Vision benefits

Flexible, paid vacation policy

Work in a flat organizational structure — direct access to Leadership