DRG Clinical (RN) Validation Auditor auditing inpatient medical records to ensure accuracy in billing and reimbursement. Specializing in Diagnosis Related Group (DRG) paid claims with a focus on clinical documentation integrity.
About the role
- Program Integrity Auditor in health compliance auditing provider records for adherence to regulations. Conducting post-payment audits and educating providers on compliance.
Responsibilities
- Conduct routine and targeted post-payment audits of Medicaid and State funded providers
- Develop audit plans and tools based on services to be audited
- Request and/or collect medical records and other documents from providers
- Identify inappropriate billing and improper payments
- Document audit activities and findings in a detailed report
- Present audit results to leadership and Compliance Committee
- Conduct due diligence reviews of newly enrolled providers
- Research clinical policies and federal/state laws for noncompliance
- Analyze data from various sources to inform decision making
- Educate providers on errors identified in the audit process
- Document Improper Payment Charts and provide feedback to providers
- Prepare for and participate in provider appeal process and/or court hearings
Requirements
- Bachelor’s degree in health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law
- Three (3) years of post-degree experience in healthcare compliance, regulatory analysis, policy development, auditing, investigations, accreditation
- Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge preferred
- Certification from AHFI, CFE, CPMA, CPC, CHC, or equivalent preferred
- Clinical license as an LCSW, LCMHC, LMFT, LCAS, or LPA preferred
- Knowledge of Alliance Health service benefit plans and network providers
- Knowledge of state and federal Medicaid laws, criminal and civil fraud laws
- Proficiency in claims adjudication standards & procedures
Benefits
- Medical
- Dental
- Vision
- Life
- Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
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