Clinical Review QC Auditor

CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. 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 its 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. This is a remote position. ESSENTIAL FUNCTIONS & 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 KNOWLEDGE & SKILLS 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 Proficient in both MS and APR DRG methodology preferred EDUCATION & EXPERIENCE LVN or RN license in the state of employment preferred Experience in the OR, ICU, or ER as an RN highly preferred 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 (preferred) or AAPC Extensive hands‑on ICD-10 CM / PCS experience required PAY RANGE Pay Range: $68,566 – $104,841 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, and paid time off. ABOUT CERIS CERIS, a division of CorVel Corporation, offers incremental value, experience, and a sincere dedication to its valued partners. Through its clinical expertise and cost containment solutions, it is committed to accuracy and transparency in healthcare payments. It is a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. It embraces its core values of Accountability, Commitment, Excellence, Integrity, and Teamwork (ACE‑IT!). CorVel is an Equal Opportunity Employer, drug‑free workplace, and complies with ADA regulations as applicable. #J-18808-Ljbffr