RN, Clinical Auditor - DRG Auditor
📍 Remote | Full-Time | 🏥 Healthcare | Clinical Documentation & Coding
About the Role
We are seeking an experienced DRG Coder / Clinical Auditor (RN) to conduct comprehensive DRG quality and validation audits of inpatient medical records. This role is critical in ensuring accurate DRG assignment, strong clinical documentation support, and compliance with Medicare and CMS regulations. The ideal candidate is highly analytical, clinically strong, and comfortable working independently in a production-driven audit environment.
You will play a key role in improving coding accuracy, reimbursement integrity, and regulatory compliance while providing clear, defensible audit findings.
Key Responsibilities
DRG Validation & Chart Review
- Perform in-depth DRG quality audits of inpatient medical records.
- Validate DRG assignments against clinical documentation and coding guidelines.
- Identify missed opportunities, discrepancies, and documentation gaps impacting reimbursement.
Clinical Documentation Review
- Evaluate physician documentation to ensure clinical indicators appropriately support assigned diagnoses and procedures.
- Apply strong clinical judgment to assess the severity of illness, risk of mortality, and DRG impact.
Audit & Compliance
- Ensure compliance with Medicare, CMS, and payer-specific documentation and coding requirements.
- Identify trends, risks, and improvement opportunities related to DRG accuracy and quality.
- Support organizational initiatives focused on audit accuracy, compliance, and revenue integrity.
Coding Expertise
- Apply extensive hands-on knowledge of ICD-10-CM and ICD-10-PCS, Coding Clinic guidance, and Official Coding Guidelines.
- Utilize MS-DRG and APR-DRG methodologies when reviewing and validating records.
Communication & Reporting
- Document audit findings clearly, concisely, and professionally.
- Communicate results and rationale effectively to internal stakeholders as required.
Additional Duties
- Support other documentation, coding, and audit-related activities as assigned.
Required Qualifications
Licensure
- Active Registered Nurse (RN) license required
- (Non-RN candidates will not be considered)
Experience
- Minimum of 2 years of recent DRG quality auditing experience in a hospital or health plan setting.
- Extensive hands-on inpatient ICD-10-CM and ICD-10-PCS coding experience required.
Certifications
- National coding certification required (AHIMA or AAPC).
- CCS, CIC, or equivalent strongly preferred.
Technical Knowledge
- Proficiency in Medicare and CMS documentation and coding guidelines.
- Strong understanding of MS-DRG and APR-DRG methodologies.
- Advanced familiarity with Coding Clinic citations and Official Coding Guidelines.
Soft Skills
- Exceptional attention to detail and analytical accuracy.
- Strong critical thinking and problem-solving skills.
- Clear, professional written and verbal communication.
- Ability to work independently in a fast-paced, production-driven environment.
Tools
- Proficient in Microsoft Office Suite (Excel, Word, Outlook).
Compensation
💵 Pay Range: $90,000 – $104,841
Compensation is based on location, experience, qualifications, and internal equity. Final compensation may vary following the interview and assessment process.
Who We Are
Headquartered in Central Florida, Pivotal Placement Services is a full-service national workforce solutions firm specializing in healthcare talent—from frontline staff to executive leadership—in both clinical and non-clinical roles. We deliver customer-focused staffing solutions through Direct Placement and MSP/VMS partnerships nationwide.
