Nurse Coder DRG Auditor III

• Independently perform DRG and APC validation using applicable coding and clinical guidelines.
• Review medical records to validate principal and secondary diagnoses, diagnosis sequencing, discharge statuses, and procedures.
• Evaluate short-stay claims to determine whether the documentation supports the medical necessity of an inpatient level of care.
• Apply CPT, ICD-10, CMS, commercial payer, InterQual, MCG, and applicable organizational policies, procedures, and regulations.
• Conduct independent audits of inpatient and outpatient claims and communicate findings clearly.
• Prepare responses to claim appeals using industry standards and applicable client and organizational policies.
• Independently validate and quality-check work completed by other team members.
• Establish and communicate coding guidelines and best practices for others to apply consistently.
• Support management with enterprise-level recommendations and strategic decision-making.
• Assist with the development of new audit concepts, methodologies, and claim selection criteria.
• Support itemized bill reviews and validation activities as needed.
• Communicate with clients when necessary to explain and support audit findings.
• Maintain all required professional licenses, certifications, continuing education, and other compliance requirements.
• Contribute to additional projects and related duties as assigned to support business and operational objectives.

Requirements

• Active RN professional license in good standing.
• Relevant clinical practice experience.
• Current coding certification in good standing, such as CCS or CIC.
• Demonstrated experience in coding validation, claims auditing, or payment integrity.
• Strong understanding of CPT and ICD-10 coding guidelines and clinical documentation.
• Ability to interpret medical records and apply coding, clinical, regulatory, and payer-specific guidelines accurately.
• Strong verbal and written communication skills, with the ability to clearly document findings and recommendations.
• Excellent organization and attention to detail, particularly when reviewing complex claims and medical documentation.
• Ability to independently prioritize multiple tasks and manage workload effectively.
• Proficiency with Microsoft Office, particularly Excel.
• Experience with appeals, APR-DRG, client communication, concept development, claim selection, or quality assurance is a plus.
• Experience in machine learning or artificial intelligence applied to healthcare or payment integrity is a plus.
• Case Management, Utilization Review, Clinical Documentation Improvement, or itemized bill validation experience is a plus.
• Previous management or leadership experience is a plus.
• RHIA or RHIT certification is a plus.
• Experience with TruCode/TruBridge, 3M, WebStrat, or similar coding and auditing platforms is a plus.
• Ability to perform sustained analytical work involving detailed reading, concentration, data review, and continuous verbal and written communication.
• Ability to work effectively in a computer-based environment and perform the repetitive typing and computer activities required for the role.
• Willingness to complete applicable compliance requirements associated with the position, which may include background or other legally permitted screening processes.

Benefits

• Competitive salary and comprehensive compensation package.
• Health insurance and other valued healthcare benefits.
• 401(k) retirement plan with employer matching.
• Paid parental leave.
• Collaborative and innovative work environment.
• Opportunity to operate as a subject matter expert and influence coding and auditing practices.
• Exposure to complex clinical coding, payment integrity, claims auditing, and healthcare compliance initiatives.
• Opportunities to contribute to strategic recommendations, new concept development, and process improvement.
• Professional growth through continuing education, certification maintenance, and cross-functional collaboration.
• Reasonable accommodations available for qualified individuals with disabilities in accordance with applicable laws.