Senior Clinical Validation Auditor at The Judge Group Inc. in Raleigh, North Carolina

Job Description:

Location: Raleigh, NC

Salary: $43.00 USD Hourly - $45.00 USD Hourly

Description: Coding & Clinical Chart Validation Specialist




Location: San Antonio, TX Address: 19500 W Interstate 10, San Antonio, TX Schedule: Monday - Friday, 8 AM - 5 PM CST (occasional after-hours and weekend work required) Start Date: March 5th (3 Non-RN hires available)



Department: Quality SDS/PSV Operations



Training: Required training hours between 8 AM - 4 PM EST. Work hours thereafter will be 8 AM - 4:30 PM EST, with flexibility up to 6 PM EST for a later start time.

Role Overview:



The Coding & Clinical Chart Validation Specialist will focus on Coding & Clinical Chart Validation for inpatient audits. This role requires a background in both clinical (nursing) and coding/auditing, particularly in Inpatient DRG/APR-DRG and/or episode of care. The specialist is responsible for auditing inpatient claims, documenting audit results, ensuring coding accuracy, clinical review, and evaluating the appropriateness of treatment settings and services delivered.

Key Responsibilities:

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  Claim Analysis & Auditing: Analyze and audit claims by integrating medical chart coding principles and clinical guidelines. Perform independent medical record reviews or episode of care reviews using advanced ICD-10 coding expertise.
  
  


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  Audit Tools Utilization: Utilize Cotiviti proprietary auditing systems proficiently to make audit determinations and generate audit letters.
  
  


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  Productivity & Quality Standards: Maintain and exceed standards/guidelines for productivity and accuracy in claim identification and documentation (letter writing).
  
  


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  New Claim Identification: Identify potential new claims outside of the concept for additional recoveries. Suggest and develop high-quality, high-value concepts, processes, and tools.
  
  


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  Special Projects: Complete responsibilities outlined in the annual performance plan and any special projects or other duties as assigned.
  
  


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  Accommodation: Perform duties with or without reasonable accommodation.
  
  

Principal Responsibilities & Essential Duties:

• Analyze and audit claims, integrating medical chart coding principles and clinical guidelines.
  
  


• Utilize audit tools proficiently to make determinations and generate audit letters.
  
  


• Maintain productivity and quality standards set by the audit operations management team.
  
  


• Identify new claim types and suggest high-value improvements.
  
  


• Perform special projects and other duties as assigned.
  
  


• Must adhere to departmental and organizational policies and procedures.
  
  

Required Qualifications:

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  Education: Associate or Bachelor's degree in Nursing (active/unrestricted license) OR Associate or Bachelor's degree in Health Information Management (RHIA or RHIT).
  
  


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  Coding/CDI Certification: RHIA, RHIT, CPC, COC, CCS, CIC, CDIP, or CCDS certification (must be maintained as a condition of employment).
  
  


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  Experience:
  
  
  
  
  • 5 to 7+ years of experience with ICD-9/10 CM, MS-DRG, AP-DRG, and APR-DRG.
    
    
  
  
  • Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
    
    
  
  
  • Expert coding knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes.
    
    
  
  
  • Adherence to official coding guidelines, coding clinic determinations, CMS, and other regulatory compliance guidelines.
    
    
  
  
  • Working knowledge of industry-based standards.
    
    
  
  
  • Proficiency in Microsoft Word, Access, Excel, TEAMS, and other applications.
    
    
  
  
  • Excellent written and verbal communication skills.
    
    
  
  
  
  

Preferred Qualifications:

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  Education: Certified Medical Assistant training or certification.
  
  


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  Experience:
  
  
  
  
  • Two or more years in a physician's clinic or hospital.
    
    
  
  
  • Additional experience as a receptionist or medical assistant in a medical care setting.
    
    
  
  
  • Bilingual proficiency in English and Spanish.
    
    
  
  
  • Three or more years of experience with data analysis/quality chart reviews.
    
    
  
  
  • One or more years of HEDIS/STAR experience or participation in similar quality regulatory reporting.
    
    
  
  
  • Knowledge and experience with EMR and HEDIS.
    
    
  
  
  
  

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Contact: eturner@judge.com


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