Clinical Review Auditor I

Job Title: Diagnostic Related Groups (DRG) 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. ESSENTIAL FUNCTIONS & RESPONSIBILITIES:The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation Conduct audits to ensure accurate reimbursement and identifying potential savings 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 RulesAssist Quality Control team and medical director with appeals, rebuttals, etc. Notify leadership of any issues or concerns in a timely manner Additional duties as assignedKNOWLEDGE & SKILLS: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 Proficiency with Microsoft OfficeEDUCATION & EXPERIENCE:LVN or RN license in the state of employment preferredCCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCSExperience in the OR, ICU, or ER as an RN highly preferredPAY 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.