Clinical Review Auditor

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

Job summary

A leading healthcare company is seeking a Clinical Review Auditor to perform DRG validation and coding reviews. The role requires strong knowledge of ICD-10 coding, excellent communication skills, and the ability to work independently while ensuring compliance with healthcare regulations. This remote position offers competitive compensation and benefits, supporting career growth in a collaborative environment.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

Disability Insurance

401K options

Paid Time Off

Qualifications

• Experience with ICD-10-CM & PCS coding guidelines.
• Knowledge of Medicare and Medicaid payer rules.

Responsibilities

• Review medical records for billing accuracy through coding verification.
• Conduct audits for accurate reimbursement and potential savings.
• Maintain HIPAA Privacy and Security compliance.

Skills

ICD-10-CM

Communication

Clinical Knowledge

Attention to Detail

Education

Current LVN or RN License

CCS or CIC Certification

Tools

Microsoft Office Suite

Job description

Join to apply for the Clinical Review Auditor role at CERIS

This position involves performing DRG validation (clinical/coding) reviews of medical records to determine correct DRG/coding, supported by review methodologies specific to the review type. Responsibilities include completing medical records review, accurately documenting findings, and providing clinical/policy/regulatory support for the determination. The ideal candidate will have experience with ICD-10-CM & PCS coding guidelines, understanding of pharmacology, disease management, and clinical intervention procedures, along with strong communication skills, clinical knowledge, and understanding of medical necessity rules.

Position Details:

• This is a remote position.

Essential Functions & Responsibilities:

• Review medical records for billing accuracy through coding verification and supporting documentation.
• Conduct audits for accurate reimbursement and potential savings.
• Possess knowledge of ICD-10-CM, PCS, DRG coding, and payer rules including Medicare and Medicaid.
• Work independently, demonstrate initiative, communicate clearly, and comply with policies.
• Maintain HIPAA Privacy and Security compliance.
• Assist team coverage, build relationships, and support Quality Control and medical directors with appeals and rebuttals.
• Proficient in basic computer skills and Microsoft Office applications.

Knowledge & Skills:

• Proficient in Medicare, CMS guidelines, and ICD-10 coding guidelines.
• Effective communication skills, ability to work independently and in a team, and adapt to a fast-paced environment.
• Proficient in Microsoft Office Suite.

Education & Experience:

• Current LVN or RN license in the state of employment, maintained during employment.
• CCS or CIC certification with DRG auditing experience in ICD-10-CM and PCS.
• Experience in the OR, ICU, or ER as an RN is highly preferred.
• Attention to detail and critical thinking skills are essential.

Pay Range: $68,566 – $104,841. Compensation is market-based, considering location, experience, and qualifications.

About Ceris: CERIS, a division of CorVel Corporation, offers clinical expertise and cost containment solutions, emphasizing accuracy and transparency in healthcare payments. We promote a supportive culture with career growth opportunities, embracing core values of Accountability, Commitment, Excellence, Integrity, and Teamwork (ACE-IT!).

Benefits include Medical, Dental, Vision, Disability, HSA, FSA, Life Insurance, 401K options, paid time off, and more. We are an Equal Opportunity Employer committed to a drug-free workplace and ADA compliance.

Additional Details:

• Seniority level: Entry level
• Employment type: Full-time
• Job function: Accounting/Auditing and Finance
• Industries: Hospitals and Healthcare