CERIS · 1 month ago
Clinical Review QC Auditor
United States
Full-time
Remote
Entry, Mid Level
$69K/yr - $105K/yr
2+ years expCERIS, a division of CorVel Corporation, is seeking a DRG Quality Control/Clinical Auditor. The role involves performing DRG validation reviews of medical records, ensuring accurate coding and reimbursement, and providing clinical support based on findings.
Health CareMedicalPayments
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
Qualification
Required
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 or AAPC
Extensive hands-on ICD-10 CM / PCS experience required
Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid
Working knowledge of HIPAA Privacy and Security Rules
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
Preferred
LVN or RN license in the state of employment
Experience in the OR, ICU, or ER as an RN
Proficient in both MS and APR DRG methodology
Benefits
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
Paid time off
Company
CERIS
CERiS is a company that detects and resolves payment issues for health claims.
501-1000 employees
Funding
Current Stage
Late StageRecent News
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