DRG Validation Auditor
Core
Ensure accurate payment of inpatient medical claims by validating DRG coding, identifying overpayments, and verifying clinical rationale with physicians.
Role type
Inpatient DRG Validation Auditor
Builds
Compliant, efficient, and profitable payment integrity programs for Clover Health members
Domain
Healthcare insurance / Medical claims adjudication
Required skills
DRG pricing methodology, Inpatient clinical coding, CCS or CIC certification, Medical records review, Claims processing, Regulatory compliance
Preferred skills
Medicare/Medicare Advantage payment integrity experience, Claims operations experience, Excel, PowerPoint
Responsibilities
Review claims for DRG related issues on prospective and retrospective basis, Identify overpayments to ensure accurate claims payments, Collaborate with MDs to verify clinical rationale behind billed procedures, Communicate with multi-discipline teams to ensure accurate claims adjudication
Seniority
Individual Contributor, Entry to Mid-level
