[Hiring] Clinical Review Auditor I @CorVel Career Site

Role Description

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.

• The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation.
• Conduct audits to ensure accurate reimbursement and identifying potential savings.
• 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.

Qualifications

• 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.

Requirements

• LVN or RN license in the state of employment preferred.
• CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS.
• Experience in the OR, ICU, or ER as an RN highly preferred.

Benefits

• 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
• Paid time off

Company Description

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!).