Auditor - Inpatient Coding (DRG Validation)

Job Summary

By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare.

Performs documentation and coding audits for all acute inpatient services for clients. Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns. Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations.

Job Competencies

Valuing Differences

Collaboration

Accountability

Time Management

Developing Trust

Takes Initiative

Essential Job Functions

Customer Obsession

Embracing New Ideas -

Striving for Excellence -

Difference Principles and consistently delivering outstanding results.

Onboarding and Training:

Mentorship:

Documentation:

Quality Audits:

Special Projects:

Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. Ensures that the assigned DRG reflects the severity of the patient’s condition and the resources used during their hospital stay.

Assesses whether the clinical documentation supports the coded diagnoses and procedures. Verifies that the medical record adequately justifies the assigned DRG.

Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities.

Maintains productivity and quality goals as set by audit leaders.

Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics.

Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations.

Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines.

Completes required education through internal application, compliance training and other mandatory educational requirements.

Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately.

Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided.

Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions.

Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies.

Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns. Shares and assists in development of concepts and or process improvement, tools, etc.

Education, Certifications & Experience

Graduate in any discipline (B.Sc./M.Sc. Nursing, B. Pharm, M. Pharm, or Life Sciences education is preferred)

Certification in Medical Billing and Coding (CPC, CCS, or equivalent) preferred.

3+ years of overall experience with 1+ years of experience in Quality Analysis within the healthcare / RCM domain.

Strong understanding of end-to-end RCM processes including charge entry, payment posting, denial management, and AR follow-up.

Knowledge of HIPAA and healthcare compliance standards.

Proficiency in using billing software (e.g., Epic, Athena, Kareo) and QA tools.

Excellent communication skills for feedback and reporting.

Attention to detail with strong analytical and problem-solving skills.

Ability to work independently and in a team environment.