Optum · 4 months ago
DRG/CVA Validation Auditor RN
Plymouth, MN
Full-time
Onsite
Mid Level
$34.23/hr - $61.15/hr
3+ years expOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. In this role as a DRG/CVA Validation Auditor RN, you will utilize your expertise in MS-DRG and APR-DRG coding to audit inpatient claims, ensuring accuracy in coding and reimbursement while identifying potential overpayments.
EducationHealth CareMedicalPharmaceutical
Responsibilities
Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing
Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements
Maintain and manage daily case review assignments, with a high emphasis on quality
Provide clinical support and expertise to the other investigative and analytical areas
Work in a high-volume production environment that is matrix driven
Qualification
Required
Associate's degree (or higher)
Unrestricted RN (Registered Nurse) license
CCS/CIC or willing to obtain certification within 6 months of hire
3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers
Preferred
Experience with prior DRG concurrent and/or retrospective overpayment identification audits
Experience with readmission reviews of claims
Experience with DRG encoder tools (ex. 3M)
Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry
Healthcare claims experience
Managed care experience
Knowledge of health insurance business, industry terminology, and regulatory guidelines
Benefits
Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
Medical Plan options along with participation in a Health Spending Account or a Health Saving account
Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
401(k) Savings Plan, Employee Stock Purchase Plan
Education Reimbursement
Employee Discounts
Employee Assistance Program
Employee Referral Bonus Program
Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
Company
Optum
Optum is a healthcare company that provides pharmacy services, health care operations, and population health management. It is a sub-organization of UnitedHealth Group.
10001+ employees
H1B Sponsorship
Optum has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
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Trends of Total Sponsorships
2025 (648)
2024 (559)
2023 (620)
2022 (851)
2021 (593)
2020 (438)
Funding
Current Stage
Late StageLeadership Team
Daniel Castillo
Chief Executive Officer, Optum Care Delivery
J
Jay Green
Chief Financial Officer
Recent News
2025-11-29
2025-11-19
2025-11-07
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