State Licensed Clinical DRG Auditor

Key responsibilities: Conduct comprehensive clinical DRG audits on inpatient claims, validating diagnoses and procedures according to CMS guidelines Produce clear audit findings and document determinations in the audit platform Collaborate with cross-functional teams to provide clinical insights that enhance audit logic and processes

Required qualifications: Active Registered Nurse (RN) license 3+ years of experience in clinical DRG validation, inpatient clinical review, or DRG auditing Strong ability to interpret inpatient medical records and assess clinical validity Experience applying clinical judgment in reimbursement or audit contexts