Clinical Review Auditor I

CERIS; Fort Worth (TX); On-site; USD 70,000 - 107,000; Full time

Benefits offered by this job

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

Paid time off

Job summary

CERIS, a division of CorVel, seeks a DRG Clinical Auditor to perform DRG validation reviews, determine correct coding, and document findings. The role requires ICD-10-CM/PCS proficiency, clinical knowledge, and familiarity with medical necessity rules.

The position emphasizes independent work, strong communication, and adherence to payer regulations, HIPAA, and internal policies in a fast-paced healthcare environment.

Qualifications

• LVN or RN license in the state of employment preferred.
• CCS or CIC certification with DRG auditing experience in ICD-10-CM, ICD-10 PCS.
• Experience in the OR, ICU, or ER as an RN highly preferred.

Responsibilities

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Conduct 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
• Understand and comply with all internal and external policies
• Working knowledge of HIPAA Privacy and Security Rules
• Assist Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of any issues or concerns in a timely manner
• Additional duties as assigned

Skills

Medicare guidelines

ICD-10-CM/PCS

Communication skills

Attention to detail

HIPAA knowledge

Microsoft Office

Education

LVN or RN license

CCS or CIC certification

OR/ICU/ER RN experience

Tools

Microsoft Office

Job description

DescriptionThe Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules.

Job Details

DescriptionThe Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules.

Essential Functions & Responsibilities

• The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Conduct 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
• Understand and comply with all internal and external policies
• Working knowledge of HIPAA Privacy and Security Rules
• Assist Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of any issues or concerns in a timely manner
• Additional duties as assigned

Knowledge & Skills

• Proficient understanding of Medicare, CMS guidelines and ICD-10 coding guidelines
• Effective and professional communication skills, both verbal and written
• Ability to work independently and in a team environment
• High attention to detail
• Must possess critical thinking skills
• Ability to multi-task and assist with team coverage and provide support when needed
• Ability to build relationships both internally and externally
• Ability to work in a fast-paced environment
• Demonstrated proficiency in basic computer skills and typing
• Proficiency with Microsoft Office

Education & Experience

• LVN or RN license in the state of employment preferred
• 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

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: $70,143 – $107,253

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.