Payment Integrity Analyst II - DRG Auditor

CERiS; Fort Worth (TX); Remote; USD 63,000 - 97,000; Full time

Job summary

CERiS is looking for a Payment Integrity Analyst to manage claim audits with a focus on compliance, accuracy, and detail-oriented review processes. This remote position requires strong knowledge of healthcare policies and claims processing, alongside excellent analytical and communication skills. Join a committed team that values accountability and integrity in healthcare management.

Benefits

Comprehensive benefits package including Medical, Dental, and Vision

401K and ROTH 401K options

Paid time off

Qualifications

• 1+ years of healthcare revenue cycle experience required.
• Experience in medical bill auditing and health insurance audits preferred.

Responsibilities

• Review and analyze claim audits based on client, policy, and CMS guidelines.
• Timely completion of internal audits and/or appeals.

Skills

Understanding of CMS and commercial payer policy

Claims processing

ICD-10 Coding

DRG Validation

Healthcare revenue cycle

Microsoft Office

Analytical skills

Interpersonal skills

Problem-solving skills

Communication skills

Education

Current LPN, LVN or RN licensure

Bachelor's degree in healthcare or related field

Job description

The Payment Integrity Analyst is responsible for accurately reviewing pre and post pay claim audits based on client, policy, industry standards and / or CMS guidelines.

This is a remote position.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :

• Reviews, analyzes, and completes internal audits and / or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication.
• Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits.
• Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and / or specialty audits.
• Utilize applicable tools and resources to complete internal audits and / or appeals.
• Timely completion of internal audits and / or appeals.
• Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings
• Additional duties as assigned.

KNOWLEDGE & SKILLS :

• Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format
• Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits
• Strong understanding of healthcare revenue cycle and claims reimbursement
• Proficient in Microsoft Office including Pivot Tables and Database Management
• Comfortable interfacing with clients and the C-Suite
• Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule
• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
• Excellent written and verbal communication skills
• Proven track record of delivering concrete results in strategic projects / programs
• Strong analytical and modeling ability and distilling data into actionable results
• Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

EDUCATION / EXPERIENCE :

• Must maintain a current LPN, LVN and / or RN licensure
• Preferred experience with health insurance denials and / or appeals, payer audits, or vendor audits
• Previous experience in one or more of the following areas required :
• Medical bill auditing
• Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical / Surgical, OB or L&D, Geriatrics and Orthopedics
• Knowledge of worker's compensation claims process
• Prospective, concurrent and retrospective utilization review
• Bachelor's degree in healthcare or related field preferred
• 1+ years healthcare revenue cycle
• 1+ years of relevant experience or equivalent combination of education and work experience
• 1+ years hospital bill audit

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 : $63,902 - $96,662

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.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.