Inpatient DRG Clinical Auditor

Inpatient DRG Clinical Auditor Remote | United States Position Overview We are seeking an experienced and analytical Inpatient DRG Clinical Auditor to join a specialized clinical review team responsible for evaluating inpatient medical records and validating Diagnosis Related Group (DRG) assignments. In this role, you will review complex hospital claims to ensure the assigned DRG is fully supported by clinical documentation and compliant with applicable coding and reimbursement guidelines. This position plays a critical role in supporting healthcare payment integrity by identifying discrepancies in clinical documentation, diagnosis coding, and DRG assignment that may impact reimbursement accuracy. The ideal candidate will have a strong background in inpatient clinical documentation review, DRG validation, or coding audit work, along with a deep understanding of inpatient hospital billing structures and coding standards. This role is well suited for nurses who have transitioned into clinical validation, DRG auditing, or coding review and who enjoy applying clinical knowledge in an analytical review environment. Key ResponsibilitiesInpatient Medical Record Review: • Conduct detailed reviews of inpatient medical records and hospital claims to validate the accuracy of DRG assignments • Evaluate the clinical documentation supporting principal diagnoses, secondary diagnoses, and proceduresimpacting DRG classification • Assess documentation to confirm the appropriate assignment of Major Complications or Comorbidities (MCC), Complications or Comorbidities (CC), and other risk-adjusting conditions • Verify whether clinical documentation supports the severity of illness and resource utilization reflected in the assigned DRG Coding and DRG Validation: • Review and validate MS-DRG or APR-DRG assignments in accordance with CMS and industry coding guidelines • Analyze ICD-10-CM and ICD-10-PCS coding to confirm accuracy and completeness • Evaluate operative reports, physician documentation, and clinical findings to determine whether coding and DRG assignments are appropriate • Identify potential coding discrepancies, documentation gaps, or DRG changes that may affect reimbursement Clinical Documentation Evaluation: • Review complex inpatient cases involving surgical procedures, high-acuity diagnoses, and specialty care services • Analyze documentation to ensure clinical findings support the assigned diagnoses and procedures • Apply clinical judgment and coding guidelines when determining whether documentation supports MCC/CC conditions or procedural coding Audit Documentation and Reporting: • Document audit findings clearly within internal review systems, including rationale for DRG validation or recommended changes • Provide detailed written explanations supporting coding or DRG adjustments • Maintain audit documentation in accordance with internal compliance standards and regulatory guidelines Quality and Production Standards: • Maintain productivity and quality expectations within a structured high-volume DRG review environment • Demonstrate strong attention to detail while reviewing complex inpatient records • Consistently meet accuracy benchmarks while managing multiple cases simultaneously Collaboration and Knowledge Development • Collaborate with coding specialists, clinical reviewers, and internal audit teams when complex cases require additional review • Remain current with updates to DRG methodologies, CMS guidelines, and ICD-10 coding standards • Support internal initiatives focused on improving documentation accuracy and DRG validation processes Required Qualifications: • Active Registered Nurse (RN) license in the state where you currently reside • 3 or more years of experience performing inpatient DRG validation, clinical documentation review, or coding audit work • Strong knowledge of MS-DRG or APR-DRG classification methodologies • Demonstrated experience reviewing inpatient hospital records for DRG accuracy • Working knowledge of ICD-10-CM and ICD-10-PCS coding systems • Experience evaluating CC and MCC conditions impacting DRG assignment • Familiarity with electronic medical record systems such as Epic, Cerner, or other hospital EMR platforms • Strong analytical and critical thinking skills for interpreting complex medical documentation • Excellent written communication skills for documenting audit findings and DRG determinations Required Certification: Candidates must hold at least one of the following professional coding or documentation certifications: • CCS (Certified Coding Specialist) – AHIMA • CCDS (Certified Clinical Documentation Specialist) • CDIP (Clinical Documentation Integrity Practitioner) • RHIA or RHIT • CPC with strong inpatient auditing experience Preferred Experience: The following experience is highly desirable: • DRG validation or clinical review in a payment integrity, payer, or audit environment • Experience reviewing complex inpatient hospital claims • Background in clinical documentation improvement (CDI) or coding compliance • Exposure to teaching hospitals, trauma centers, or high-acuity inpatient environments • Experience using coding encoders or DRG validation tools Work Environment: • Fully remote position within the United States • Structured review environment with established productivity and quality standards • Collaborative clinical audit team supporting reimbursement accuracy and regulatory compliance • Opportunities to work with experienced DRG auditors and clinical documentation specialists Ideal Candidate Profile: Successful candidates typically have experience in roles such as: • Inpatient DRG auditor • Clinical validation reviewer • Clinical documentation integrity specialist • Coding compliance auditor • Payment integrity nurse reviewer This role is best suited for nurses who enjoy applying their clinical knowledge to detailed documentation analysis, coding validation, and DRG accuracy review rather than direct patient care responsibilities. Application Process: Qualified candidates should submit: • An updated resume highlighting inpatient DRG validation or clinical documentation review experience • Current RN license information for the state in which they reside • Details regarding relevant coding or documentation certifications Selected applicants will be contacted to schedule an initial screening discussion focused on their experience with inpatient DRG validation and clinical documentation auditing. Pay: $80,000.00 - $95,000.00 per year Benefits: • 401(k) • 401(k) matching • Dental insurance • Employee assistance program • Employee discount • Flexible schedule • Flexible spending account • Health insurance • Health savings account • Life insurance • Paid time off • Retirement plan • Vision insurance Application Question(s): • Please describe your experience reviewing inpatient hospital records to validate MS-DRG or APR-DRG assignments. Please Include: The type of organization you worked for (payer, audit firm, health plan, etc.) Your role in the DRG validation process The types of cases or hospitals you typically reviewed • When reviewing an inpatient chart, how do you determine whether a documented condition qualifies as a CC or MCC for DRG assignment? Please describe your approach to evaluating documentation and identifying whether the condition meets coding and clinical support requirements. • Which coding systems have you used when performing inpatient DRG reviews? Please describe your experience with: ICD-10-CM ICD-10-PCS MS-DRG or APR-DRG methodologies Coding encoders or DRG grouping tools • Please list all coding or documentation certifications you currently hold. Examples include: CCS CCDS CDIP RHIA / RHIT CPC (with inpatient audit experience) Please include the issuing organization and certification status. • Are you currently working in a role where you perform inpatient DRG validation or clinical documentation review? If yes, please briefly describe: Your current job title The types of inpatient cases you review Your typical review volume per day License/Certification: • RN License (Preferred) • LVN (Preferred) Location: • United States (Preferred) Work Location: Remote