DRG Validation Auditor (Clinical & Coding)

Overview

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits (DRG Validation). The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.

Start date is 8/31/2026 or 10/5/2026

Responsibilities

• Analyzes and Audits Claims. Integrates medical chart coding principles, clinical guidelines and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.
• Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
• Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.
• Meets or Exceed Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim, identification and documentation (letter writing).
• Identifies New Claim Types.
• Identifies potential claims outside of the concept where additional recoveries may be available.
• Suggests and develops high quality, high value concept and or process improvement, tools, etc.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

Qualifications

Education (at least one of the following are required)

• Associate or bachelor's degree in nursing (active /unrestricted license).
• Associate or bachelor's degree Health Information Management (RHIA or RHIT).
• High school diploma or GED plus equivalent experience of 5+ years' experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment.

Coding/CDI Certification (at least one of the following are required and are to be maintained as a condition of employment):

• RHIA or RHIT.
• CPC.
• Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.

Experience (required)

• 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codes.
• Requires working knowledge of and applicable industry-based standards.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

Mental Requirements

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.

Physical Requirements and Working Conditions

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
• No adverse environmental conditions expected.

Base compensation is paid hourly at $45.67 per hour (95k annualized). This role is eligible for discretionary bonus consideration.

Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.