Nurse Coder DRG Auditor III

Accountabilities • Independently perform DRG and APC validation using applicable coding and clinical guidelines.

• Review medical records to validate principal and secondary diagnoses, diagnosis sequencing, discharge statuses, and procedures.

• Evaluate short-stay claims to determine whether the documentation supports the medical necessity of an inpatient level of care.

• Apply CPT, ICD-10, CMS, commercial payer, InterQual, MCG, and applicable organizational policies, procedures, and regulations.

• Conduct independent audits of inpatient and outpatient claims and communicate findings clearly.

• Prepare responses to claim appeals using industry standards and applicable client and organizational policies.

• Independently validate and quality-check work completed by other team members.

• Establish and communicate coding guidelines and best practices for others to apply consistently.

• Support management with enterprise-level recommendations and strategic decision-making.

• Assist with the development of new audit concepts, methodologies, and claim selection criteria.

• Support itemized bill reviews and validation activities as needed.

• Communicate with clients when necessary to explain and support audit findings.

• Maintain all required professional licenses, certifications, continuing education, and other compliance requirements.

• Contribute to additional projects and related duties as assigned to support business and operational objectives.

Requirements

• Active RN professional license in good standing.

• Relevant clinical practice experience.

• Current coding certification in good standing, such as CCS or CIC.

• Demonstrated experience in coding validation, claims auditing, or payment integrity.

• Strong understanding of CPT and ICD-10 coding guidelines and clinical documentation.

• Ability to interpret medical records and apply coding, clinical, regulatory, and payer-specific guidelines accurately.

• Strong verbal and written communication skills, with the ability to clearly document findings and recommendations.

• Excellent organization and attention to detail, particularly when reviewing complex claims and medical documentation.

• Ability to independently prioritize multiple tasks and manage workload effectively.

• Proficiency with Microsoft Office, particularly Excel.

• Experience with appeals, APR-DRG, client communication, concept development, claim selection, or quality assurance is a plus.

• Experience in machine learning or artificial intelligence applied to healthcare or payment integrity is a plus.

• Case Management, Utilization Review, Clinical Documentation Improvement, or itemized bill validation experience is a plus.

• Previous management or leadership experience is a plus.

• RHIA or RHIT certification is a plus.

• Experience with TruCode/TruBridge, 3M, WebStrat, or similar coding and auditing platforms is a plus.

• Ability to perform sustained analytical work involving detailed reading, concentration, data review, and continuous verbal and written communication.

• Ability to work effectively in a computer-based environment and perform the repetitive typing and computer activities required for the role.

• Willingness to complete applicable compliance requirements associated with the position, which may include background or other legally permitted screening processes.

Benefits

• Competitive salary and comprehensive compensation package.

• Health insurance and other valued healthcare benefits.

• 401(k) retirement plan with employer matching.

• Paid parental leave.

• Collaborative and innovative work environment.

• Opportunity to operate as a subject matter expert and influence coding and auditing practices.

• Exposure to complex clinical coding, payment integrity, claims auditing, and healthcare compliance initiatives.

• Opportunities to contribute to strategic recommendations, new concept development, and process improvement.

• Professional growth through continuing education, certification maintenance, and cross-functional collaboration.

• Reasonable accommodations available for qualified individuals with disabilities in accordance with applicable laws.

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