Inpatient DRG Validation Auditor (RN)

We are seeking an experienced Inpatient DRG Validation Auditor (RN) with strong expertise in clinical documentation review and DRG validation. In this role, you will review inpatient medical records to confirm the accuracy of coded diagnoses and procedures, ensure appropriate DRG assignment, and verify that clinical documentation supports billed services in accordance with payer and regulatory requirements. The ideal candidate brings a strong clinical foundation, advanced knowledge of inpatient coding guidelines, and the ability to analyze medical records to determine whether diagnoses and services are clinically supported. This position plays a key role in protecting reimbursement accuracy and maintaining compliance with CMS and payer standards. This is a fully remote, work-from-home opportunity. Essential Responsibilities • Review inpatient medical records to validate DRG assignments and confirm the accuracy of coded diagnoses and procedures . • Evaluate clinical documentation to ensure that billed services are supported by appropriate clinical indicators, treatment documentation, and severity of illness (SOI) . • Apply knowledge of ICD-10-CM, ICD-10-PCS, and DRG methodologies (MS-DRG and APR-DRG) when performing medical record reviews . • Interpret and apply Medicare, Medicaid, and payer-specific guidelines related to inpatient coding and reimbursement. • Identify discrepancies in coding or clinical documentation, such as upcoding or incorrect CC/MCC capture, that may impact reimbursement. • Document audit findings with clear clinical reasoning and appropriate regulatory or coding references to support DRG downgrades. • Maintain high-volume productivity standards and quality standards while conducting detailed chart reviews. • Collaborate with quality review teams, medical leadership, and compliance teams as needed for appeals, rebuttals, or escalated cases . • Communicate audit outcomes, documentation concerns, and process improvements to appropriate stakeholders. • Maintain compliance with HIPAA privacy and security standards. • Perform additional duties as needed to support departmental goals. Knowledge & Skills • Strong analytical and critical thinking abilities. • High attention to detail when reviewing medical records and documentation. • Ability to evaluate clinical indicators including labs, vital signs, and treatment response to validate a diagnosis. • Clear and professional written communication for audit documentation and rationales. • Ability to work independently in a structured, production-driven remote environment. • Strong time management and ability to meet strict productivity expectations. • Proficiency with Microsoft Office, 3M 360/Encompass, and Epic/Cerner EMR systems. Required Qualifications • Active, unrestricted Registered Nurse (RN) license. • Associate Degree in Nursing (ADN) or higher • Prior experience in a Payer or Payment Integrity Vendor environment performing DRG validation or clinical review. • Working knowledge of ICD-10-CM and ICD-10-PCS coding systems. • Experience applying CMS guidelines and Medicare reimbursement rules. • CCS (Certified Coding Specialist) or CIC (Certified Inpatient Coder) certification Preferred Qualifications • CDIP (Clinical Documentation Improvement Practitioner), or RHIA certification. • Clinical background in acute care hospital settings, particularly ICU, Emergency Department, or other high-acuity units • Experience with MS-DRG or APR-DRG methodology • Previous experience in revenue integrity, CDI, or inpatient DRG auditing Pay: $70,000.00 - $100,000.00 per year Benefits: • 401(k) • Dental insurance • Flexible schedule • Health insurance • Paid time off • Vision insurance Application Question(s): • Describe your experience with MS-DRG or APR-DRG methodologies. Specifically, how do you identify when a CC/MCC capture or a sequencing error has led to an incorrect reimbursement? • Do you have at least 2 years of clinical nursing experience in a high-acuity hospital setting (e.g., ICU, ER, Trauma, or Step-down)? If so, please specify your primary clinical role(s) and the acuity level of the unit(s). • What is your process for identifying Unbundling or inappropriate charges in a complex medical record? How do you apply CMS guidelines to ensure services aren't being billed separately when they should be bundled? • When you recommend a DRG downgrade or a denial, what specific evidence (clinical or coding) do you include in your rationale to ensure it is defensible against a hospital appeal? Work Location: Remote