Clinical Review QC Auditor
About the position CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. The 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. This is a remote position. Responsibilities • Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation • Check for physician's notes supporting the DRGs assigned • Conduct audits to ensure accurate reimbursement and identifying potential savings • Review previously conducted audits to ensure accurate coding and identifying potential savings • Review all opportunities sent to the customers for complete and correct information • 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 Requirements • Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations • Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments • 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 • LVN or RN license in the state of employment preferred • Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan. • National Coding Certification required through either AHIMA (preferred) or AAPC • Extensive hands-on ICD-10 CM / PCS experience required Nice-to-haves • Proficient in both MS and APR DRG methodology preferred • Experience in the OR, ICU, or ER as an RN highly preferred Benefits • 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. Apply tot his job