Patient Safety DRG Clinical Validation Auditor
Core
Audits inpatient medical records to ensure clinical documentation supports billed Diagnosis Related Groups (DRGs) and reimbursement.
Role type
Senior clinical auditor (medical records/DRG)
Builds
Validated DRG claims and audit findings letters
Domain
Healthcare administration / Medical coding
Required skills
Registered Nurse license, ICD-10 coding, MS-DRG/AP-DRG/APR-DRG expertise, claims auditing, clinical documentation improvement, medical chart review, audit tools proficiency, process improvement
Preferred skills
CCDS, CDIP, CPC, CCS, CIC certifications, third-party DRG coding experience, payer reimbursement policy knowledge
Technologies
ICD-10CM, MS-DRG, AP-DRG, APR-DRG, audit workflow systems
Responsibilities
Analyze and audit claims by integrating medical chart coding principles and clinical guidelines; Utilize audit tools to generate determinations and formulate detailed audit findings letters; Identify potential documentation and coding errors such as inappropriate billing for readmissions or Hospital-Acquired Conditions; Suggest and develop high-quality process improvement and efficiency recommendations
Seniority
Senior, specialized IC
