Clinical Review Auditor

CorVel Corporation; Fort Worth (TX); Remote; USD 60,000 - 75,000; Full time

Job summary

A leading company is seeking a Clinical Review Auditor to perform DRG validation reviews of medical records. The role requires strong communication skills and clinical knowledge, along with proficiency in ICD-10 coding. This remote position involves auditing for billing accuracy and ensuring compliance with medical necessity rules.

Qualifications

• Experience using ICD-10-CM & PCS coding guidelines.
• DRG auditing experience required.

Responsibilities

• Review medical records for billing accuracy.
• Conduct audits to ensure accurate reimbursement.
• Support Quality Control team with appeals.

Skills

Communication

Clinical Knowledge

Attention to Detail

Critical Thinking

Education

Current LVN or RN license

CCS or CIC certification

Tools

Microsoft Office

Job description

Join to apply for the Clinical Review Auditor role at CorVel Corporation.

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, understanding modern pharmacology, disease management, and clinical intervention procedures are required. The ideal candidate will have strong communication skills, clinical knowledge of disease processes, and understanding of medical necessity rules.

This is a remote position.

Essential Functions & Responsibilities

• Review medical records to verify billing accuracy through coding verification and supporting documentation.
• Conduct audits to ensure accurate reimbursement and identify potential savings.
• Possess knowledge of ICD-10-CM, PCS, DRG coding, and payer rules including Medicare and Medicaid.
• Work independently with minimal supervision and demonstrate initiative.
• Communicate clearly and accurately.
• Comply with all internal and external policies.
• Maintain knowledge of HIPAA Privacy and Security Rules.
• Assist with team coverage and support when needed.
• Build relationships internally and externally.
• Support Quality Control team and medical director with appeals and rebuttals.
• Proficient in basic computer skills and Microsoft Office Suite.
• Report issues or concerns to management promptly.
• Perform additional duties as assigned.

Knowledge & Skills

• Proficiency in Medicare, CMS guidelines, and ICD-10 coding.
• Effective communication skills, both verbal and written.
• Ability to work independently and in a team environment.
• Ability to work in a fast-paced environment.
• Proficiency in Microsoft Office.

Education & Experience

• Current LVN or RN license in the state of employment.
• License must be maintained during employment.
• CCS or CIC certification required, 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.