Clinical Review Auditor I

Job DetailsDescriptionThe 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.This is a remote position.Essential Functions & ResponsibilitiesThe Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentationConduct audits to ensure accurate reimbursement and identifying potential savingsDemonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and MedicaidUnderstand and comply with all internal and external policiesWorking knowledge of HIPAA Privacy and Security RulesAssist Quality Control team and medical director with appeals, rebuttals, etc.Notify leadership of any issues or concerns in a timely mannerAdditional duties as assignedKnowledge & SkillsProficient understanding of Medicare, CMS guidelines and ICD-10 coding guidelinesEffective and professional communication skills, both verbal and writtenAbility to work independently and in a team environmentHigh attention to detailMust possess critical thinking skillsAbility to multi-task and assist with team coverage and provide support when neededAbility to build relationships both internally and externallyAbility to work in a fast-paced environmentDemonstrated proficiency in basic computer skills and typingProficiency with Microsoft OfficeEducation & ExperienceLVN or RN license in the state of employment preferredCCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCSExperience in the OR, ICU, or ER as an RN highly preferredPay RangeCorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.Pay Range: $63,739 – $95,264A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk ManagementIn general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.About CerisCERIS, 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!).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.CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.