DRG Clinical Auditor Principal
Core
Auditing inpatient medical records on claims paid based on Diagnostic Related Group (DRG) methodology, including case rate and per diem, to generate complex audit findings and recoverable claims.
Role type
Principal DRG Clinical Auditor
Builds
Recoverable claims and audit findings for the company and its clients
Domain
Healthcare administration / Medical claims auditing
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Advanced ICD-10 coding expertise, DRG coding methodology knowledge (MS-DRG, APR-DRG, AP-DRG, TRICARE), clinical guidelines interpretation, audit tool utilization, secondary audit review, process improvement identification
Preferred skills
Vendor-based DRG coding audit experience, hospital coding environment experience, payer reimbursement policy knowledge, RN license
Technologies
ICD-10, ICD-9, MS-DRG, AP-DRG, APR-DRG, TRICARE, audit workflow systems
Responsibilities
Analyze and audit claims integrating advanced medical chart coding principles and complex clinical guidelines; Validate accuracy and quality standards for lower-level auditors; Identify new claim types and potential recoveries (e.g., re-admissions, HACs, PAEs); Perform secondary audits on claims reviewed by other coders; Collaborate with management to improve selection criteria
Seniority
Principal, highly experienced IC