DRG Nurse Auditor

DRG Nurse Auditor

The Atlantic Region CBO is seeking a dynamic and talented DRG Nurse Auditor with clinical case management experience to be responsible for analyzing clinical claim denials, drafting detailed appeal letters, evaluating clinical level of care, and the review of denial trends. Key responsibilities include: perform DRG (Diagnosis Related Group) validation reviews in response to audits from third party payers. Review audit findings letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying payer clinical/coding rationale. Analyze medical records to obtain supporting clinical documentation for billed diagnosis codes. Communicate findings to third party payers in detailed appeal letters to prevent downgrade payment recoveries. Make decisions to update DRGs or remove or add to billed diagnose codes based on clinical reviews. Call third party payers and physician offices as needed to obtain additional clinical details. Identify audit trends and provide feedback to management and to UHS acute care facilities. Adherence to all applicable laws, regulations and guidelines. Other duties as assigned.

Benefit highlights include: challenging and rewarding work environment, competitive compensation & generous paid time off, excellent medical, dental, vision and prescription drug plans, 401(k) with company match and discounted stock plan, SoFi student loan refinancing program, and career development opportunities within UHS and its 300+ subsidiaries.

About Universal Health Services: One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World's Most Admired Companies by Fortune; listed in Forbes ranking of America's Largest Public Companies. Headquarters in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Position requirements include: RN or LPN licensure in good standing is required. BSN degree preferred. Three to five years of experience is preferred. Working knowledge of coding regulations including ICD-10, DRGs, and HCPCs. CPC, CCS or other coding credentials preferred, but not required. CDI experience is preferred. CCDS certification is preferred. Experience working in patient financial services and an understanding of the revenue cycle from beginning to end is preferred. Experience working in case management or audit with technical denials is preferred. Strong Microsoft Office skills (Excel, Word, Outlook). Customer focused both internally and externally, strong attention to detail, the ability to multi-task. Excellent written and oral communication skills are required.