DRG Clinical Validation Auditor

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Job Description:

Responsible for collaborating with healthcare providers, medical directors, and members to ensure medically appropriate, high quality, and cost effective care. This role combines utilization management, medical necessity review, and inpatient DRG auditing, applying clinical expertise and advanced medical coding knowledge to support accurate authorization, documentation integrity, and reimbursement. The DRG Auditor conducts clinical reviews across the care continuum while ensuring alignment between clinical documentation, diagnosis/procedure coding, DRG assignment, and payer reimbursement policies. Conducts pre certification, concurrent/continued stay, retrospective review, care coordination, and discharge planning for inpatient and outpatient services. Reviews inpatient admissions, outpatient services, surgical and diagnostic procedures, admission status, and le...