Clinical Review Auditor

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!).

The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding and clinically supported as defined by review methodologies specific to the type of review. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. Experience using ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules. This is a remote position.

The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and supporting clinical documentation Conducting 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 The ability to work independently with minimal supervision and demonstrate initiative Able to communicate clearly and accurately Clearly understands and comply with all internal and external policies Working knowledge of HIPAA Privacy and Security Rules Ability to multi-task and assist with team coverage and provide support when needed Ability to build relationships both internally and externally Assists Quality Control team and medical director with Appeals, Rebuttals, etc. Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc. Notify manager/leadership of any issues or concerns in a timely manner Additional duties as assigned by leadership