Clinical Review Auditor

CERIS; Fort Worth (TX); Remote; USD 68,000 - 105,000; Full time

Job summary

CERIS is seeking a Clinical Review Auditor to perform DRG validation reviews of medical records. The ideal candidate will have a current RN or LVN license, experience in auditing, and a thorough understanding of ICD-10 coding. This is a remote role offering competitive pay and benefits.

Benefits

Comprehensive benefits package

Flexible Spending Account Options

401K and ROTH 401K

Paid time off

Qualifications

• Current LVN or RN license required.
• CCS or CIC with DRG auditing experience needed.
• Experience in the OR, ICU, or ER preferred.

Responsibilities

• Review medical records for accurate billing and verify coding.
• Conduct audits for accurate reimbursement.
• Comply with HIPAA Privacy and Security Rules.

Skills

ICD-10-CM knowledge

Communication skills

Critical thinking

Knowledge of medical necessity rules

Education

LVN or RN license

CCS or CIC certification

Tools

Microsoft Office Suite

Job description

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Description

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.

Job Details

Description

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
• Extreme attention to detail
• Must possess critical thinking skills
  
  

Pay Range

CorVel 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.

Pay Range: $68,566 – $104,841

A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management

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 CorVel 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, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Accounting/Auditing and Finance

• Industries

  Hospitals and Health Care

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