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Alaffia Health · 7 hours ago

Clinical DRG Auditor

United States

Full-time

Remote

Mid Level

$85K/yr - $95K/yr

3+ years exp

Alaffia Health is a high-growth, venture-backed startup focused on reducing waste in the U.S. healthcare system through advanced AI. They are seeking an experienced Clinical DRG Auditor to perform inpatient Diagnosis-Related Group (DRG) validation audits and clinical reviews, leveraging clinical expertise to improve payment accuracy and inform audit automation.

Artificial Intelligence (AI)Health CareMachine Learning

Responsibilities

Perform comprehensive clinical DRG audits on inpatient claims, including validation of principal diagnosis, secondary diagnoses, CCs/MCCs, procedures, sequencing, and discharge status

Evaluate whether clinical documentation supports the billed DRG in accordance with CMS guidelines, payer policies, and nationally accepted standards of care

Apply clinical judgment and clinical guidelines to interpret complex inpatient medical records, including physician notes, labs, imaging, procedures, and treatment plans

Identify documentation gaps, unsupported diagnoses, and DRG upcoding or misclassification

Produce clear, defensible audit findings with concise clinical rationale

Accurately document audit determinations in Alaffia’s audit platform and supporting tools

Support quality assurance processes and peer review as needed

Maintain working knowledge of ICD-10-CM/PCS coding principles, DRG groupers (MS-DRG, APR-DRG, AP-DRG as applicable), CMS guidance, and payer-specific reimbursement policies

Ensure all audit activity complies with HIPAA, regulatory requirements, and internal SOPs

Collaborate with payment integrity operations, product, and engineering teams to provide clinical insight that informs audit logic and AI-driven review models

Contribute to ongoing process improvements, training, and audit optimization initiatives

Qualification

Clinical DRG auditingInpatient clinical reviewICD-10-CM/PCS codingClinical judgmentReimbursement methodologiesAudit platformsAnalytical skillsCritical-thinking skillsWritten communicationAttention to detail