Auditor

• review medical records and associated claim information to validate accuracy of DRG assignments and/or medical necessity for inpatient level of care
• Utilize coding guidelines and clinical guidelines to perform DRG validation
• Validate principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses and procedures utilizing the medical record
• Evaluate short stay claims for medical necessity of an inpatient level of care
• Apply CPT and ICD-10 guidelines
• Apply policies, procedures, guidelines and regulations developed by Centers for Medicare and Medicaid Services (CMS), commercial payers, InterQual, MCG, and Trend Health Partners
• Provide appeal responses for claims of the above types utilizing industry standards and company/client policies
• Assist with new concept development
• Assist with claim selection criteria
• Assist with itemized bill review as needed
• Maintain licensures, certifications and continuing education requirements
• May require client communication to support findings

Nurse Coder, DRG Auditor I

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