[Remote] Clinical Reviewer / DRG Validator - 250793
Note: The job is a remote job and is open to candidates in USA. Medix™ is seeking an experienced Auditor / Validator to perform comprehensive DRG and clinical validation reviews in support of accurate reimbursement and regulatory compliance. The Clinical Auditor will examine inpatient medical records to confirm billing accuracy by validating code assignment and ensuring appropriate clinical documentation.
Responsibilities
• Perform concurrent and retrospective clinical validation reviews for MS-DRG and APR-DRG assignments
• Validate accurate assignment of ICD-10-CM diagnosis and ICD-10-PCS procedure codes
• Utilize encoders, EMRs, and auditing tools (e.g., 3M, EPIC, TruCode) to support audit determinations
• Prepare clear, concise audit rationales and documentation findings
• Draft physician queries to clarify documentation and ensure coding accuracy
• Provide coder education referencing Official Coding Guidelines and AHA Coding Clinic
• Review DRG and coding denials; draft well-supported appeal letters to payers, RAC, PRO, and third-party auditors
• Issue written recommendations for optimal coding, DRG, and SOI assignment
• Support Quality Control team and Medical Director with appeal reviews and rebuttals
• Maintain strong knowledge of ICD-10-CM/PCS, DRG methodologies, payer policies, and regulatory requirements (Medicare/Medicaid)
• Communicate effectively with physicians, CDI staff, coders, and clinical teams
• Escalate identified compliance or documentation concerns to leadership as appropriate
• Adhere to organizational policies, HIPAA Privacy and Security standards, and all applicable regulations
• Meet or exceed productivity and quality standards (95–100% accuracy required)
• Manage multiple priorities in a fast-paced environment and contribute to team coverage
• Perform additional duties as assigned
Skills
• AHIMA certification required: CIC, CCS, RHIT, or RHIA OR current LVN or RN license in the state of employment (license must be maintained during employment)
• CPC accepted if willing to obtain CCS or CIC within 1 year of hire (and relevant experience)
• If LVN/RN without CIC/CCS, must obtain within 1 year of hire
• 5+ years of DRG/Clinical Validation, claims auditing, quality assurance, or recovery auditing experience preferred
• 5+ years of hands-on ICD-10-CM/PCS, MS-DRG, and APR-DRG experience
• Strong knowledge of Medicare, CMS regulations, Official Coding Guidelines, Coding Clinic, and compliance standards
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)
• Experience with 3M, TruCode, EPIC, Teams, SharePoint, and related systems
Company Overview
• Medix provides workforce solutions to clients and creates opportunity for contract employees. It was founded in 2001, and is headquartered in Chicago, Illinois, USA, with a workforce of 501-1000 employees. Its website is http://www.medixteam.com/.
Apply Now
Apply Now
Responsibilities
• Perform concurrent and retrospective clinical validation reviews for MS-DRG and APR-DRG assignments
• Validate accurate assignment of ICD-10-CM diagnosis and ICD-10-PCS procedure codes
• Utilize encoders, EMRs, and auditing tools (e.g., 3M, EPIC, TruCode) to support audit determinations
• Prepare clear, concise audit rationales and documentation findings
• Draft physician queries to clarify documentation and ensure coding accuracy
• Provide coder education referencing Official Coding Guidelines and AHA Coding Clinic
• Review DRG and coding denials; draft well-supported appeal letters to payers, RAC, PRO, and third-party auditors
• Issue written recommendations for optimal coding, DRG, and SOI assignment
• Support Quality Control team and Medical Director with appeal reviews and rebuttals
• Maintain strong knowledge of ICD-10-CM/PCS, DRG methodologies, payer policies, and regulatory requirements (Medicare/Medicaid)
• Communicate effectively with physicians, CDI staff, coders, and clinical teams
• Escalate identified compliance or documentation concerns to leadership as appropriate
• Adhere to organizational policies, HIPAA Privacy and Security standards, and all applicable regulations
• Meet or exceed productivity and quality standards (95–100% accuracy required)
• Manage multiple priorities in a fast-paced environment and contribute to team coverage
• Perform additional duties as assigned
Skills
• AHIMA certification required: CIC, CCS, RHIT, or RHIA OR current LVN or RN license in the state of employment (license must be maintained during employment)
• CPC accepted if willing to obtain CCS or CIC within 1 year of hire (and relevant experience)
• If LVN/RN without CIC/CCS, must obtain within 1 year of hire
• 5+ years of DRG/Clinical Validation, claims auditing, quality assurance, or recovery auditing experience preferred
• 5+ years of hands-on ICD-10-CM/PCS, MS-DRG, and APR-DRG experience
• Strong knowledge of Medicare, CMS regulations, Official Coding Guidelines, Coding Clinic, and compliance standards
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)
• Experience with 3M, TruCode, EPIC, Teams, SharePoint, and related systems
Company Overview
• Medix provides workforce solutions to clients and creates opportunity for contract employees. It was founded in 2001, and is headquartered in Chicago, Illinois, USA, with a workforce of 501-1000 employees. Its website is http://www.medixteam.com/.
Apply Now
Apply Now