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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.
ESSENTIAL FUNCTIONS & 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
KNOWLEDGE & SKILLS:
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
Proficiency with Microsoft Office
Proficient in both MS and APR DRG methodology preferred
EDUCATION & EXPERIENCE:
LVN or RN license in the state of employment preferred
Experience in the OR, ICU, or ER as an RN highly 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
PAY 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.
Pay Range: $68,566 – $104,841 A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.
ABOUT CERIS :
CERIS , a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes 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.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.