This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an Auditor Clinical Validation DRG based in United States.
This role plays a critical part in ensuring the accuracy, compliance, and integrity of inpatient medical claims through detailed clinical and coding validation. The specialist will review complex inpatient records, applying advanced DRG, APR-DRG, and ICD-10 coding expertise to assess appropriateness of care, billing accuracy, and medical necessity. Working independently in a remote environment, this professional contributes to identifying recovery opportunities and improving audit processes that directly impact healthcare cost integrity and quality assurance. The position requires strong clinical judgment, analytical precision, and the ability to translate medical documentation into accurate audit outcomes. It is well-suited for experienced healthcare auditors or clinicians with a strong coding background who thrive in detail-oriented, compliance-driven work. This role also offers the opportunity to contribute to process improvements in a fast-paced, data-driven audit environment. Strong communication and consistency in high-quality documentation are essential to success.
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an Auditor Clinical Validation DRG based in United States.
This role plays a critical part in ensuring the accuracy, compliance, and integrity of inpatient medical claims through detailed clinical and coding validation. The specialist will review complex inpatient records, applying advanced DRG, APR-DRG, and ICD-10 coding expertise to assess appropriateness of care, billing accuracy, and medical necessity. Working independently in a remote environment, this professional contributes to identifying recovery opportunities and improving audit processes that directly impact healthcare cost integrity and quality assurance. The position requires strong clinical judgment, analytical precision, and the ability to translate medical documentation into accurate audit outcomes. It is well-suited for experienced healthcare auditors or clinicians with a strong coding background who thrive in detail-oriented, compliance-driven work. This role also offers the opportunity to contribute to process improvements in a fast-paced, data-driven audit environment. Strong communication and consistency in high-quality documentation are essential to success.
Accountabilities:
- Conduct comprehensive inpatient claims audits using clinical records, coding guidelines, and regulatory standards to validate DRG/APR-DRG assignments.
- Apply advanced ICD-10, MS-DRG, APR-DRG, and related coding knowledge to support audit findings and ensure compliance with payer and CMS guidelines.
- Utilize proprietary audit systems and tools to document findings, generate audit determinations, and prepare formal audit correspondence.
- Maintain required productivity levels while ensuring accuracy, quality, and adherence to audit standards.
- Identify claims outside of standard audit scope that may present additional recovery opportunities or risk areas.
- Contribute to continuous improvement efforts by suggesting enhancements to audit tools, methodologies, and workflows.
- Complete assigned responsibilities, special projects, and performance objectives in alignment with organizational expectations.
- Associate or bachelor’s degree in Nursing (active, unrestricted license) OR Health Information Management (RHIA/RHIT) OR equivalent experience with high school diploma/GED and 5+ years in auditing or healthcare claims.
- One or more active certifications required: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.
- 5–7+ years of experience working with ICD-9/10, MS-DRG, APR-DRG, and inpatient coding and billing systems.
- Strong knowledge of medical necessity criteria, payer reimbursement rules, and regulatory compliance standards (CMS and coding clinic guidance).
- Proficiency with standard office tools such as Word, Excel, Access, and collaboration platforms like Microsoft Teams.
- Strong analytical thinking, attention to detail, and ability to assess complex medical documentation accurately.
- Excellent written and verbal communication skills for audit documentation and findings.
- Ability to work independently in a remote environment with a secure, dedicated workspace and reliable high-speed internet.
- Competitive hourly compensation (approximately $45.67/hour, annualized around $95K)
- Eligibility for discretionary performance bonus
- Comprehensive medical, dental, vision, life, and disability insurance coverage
- 401(k) retirement savings plan
- Paid family leave and paid holidays (9 per year)
- Generous PTO allowance (17–27 days depending on tenure and level)
- Fully remote work arrangement with flexible home-office setup requirements
- Opportunity to work on high-impact healthcare audit and compliance initiatives
The Auditor Clinical Validation DRG is responsible for performing detailed inpatient claim audits with a focus on clinical accuracy, coding compliance, and reimbursement integrity.
Requirements:
This role requires strong clinical and coding expertise combined with experience in healthcare auditing, claims validation, or revenue integrity environments. Candidates must be highly detail-oriented and comfortable working independently in a structured, compliance-focused setting.