Clinical Validation Auditor - RN auditing inpatient medical records to ensure accurate clinical documentation. Role requires extensive experience in claims auditing and knowledge of DRGs.
About the role
- Coding Investigator Auditor responsible for clinical, billing, and coding reviews at HCSC. Validating claims and coordinating with various departments for accurate outcomes.
Responsibilities
- Performing clinical, billing, coding and lowest cost setting reviews for services pre and post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed.
- Conducting research; preparing documentation of findings and consulting with medical directors as needed.
- Coordination with all departments involved in each case required such as special investigations, customer service, pass, network management, marketing, case management, medical review, legal, pricing and database.
Requirements
- Bachelor Degree
- One year of business experience, law enforcement experience, or regulatory agency experience may substitute for each year of college.
- Certified Coding Certification, or acquire within 24 months of hire
- 3 years experience in claims processing operations and reporting systems, including 2 years experience in auditing or developing computer system reports.
- Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation.
- Awareness of claims processes and claims processing systems.
- PC proficiency to include Microsoft Word and Excel and health insurance databases.
- Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings.
- Organizational skills and prioritization skills.
Benefits
- Health insurance
- 401(k) savings plan
- Pension plan
- Paid time off
- Paid parental leave
- Disability insurance
- Supplemental life insurance
- Employee assistance program
- Paid holidays
- Tuition reimbursement
Job title
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