New York Licensed Clinical Auditor

Job Summary

To enhance payment accuracy, the full-time remote Clinical DRG Auditor will conduct inpatient Diagnosis-Related Group (DRG) validation audits and detailed clinical reviews of medical records and claims, leveraging clinical expertise to identify unsupported DRGs and improve audit automation.

Key responsibilities

• Perform comprehensive clinical DRG audits on inpatient claims, validating diagnoses, procedures, and discharge status
• Produce clear audit findings and document determinations in the audit platform
• Collaborate with cross-functional teams to provide clinical insights that inform audit logic and process improvements

Required qualifications

• Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license
• 3+ years of experience in clinical DRG validation, inpatient clinical review, or similar payment integrity work
• Strong ability to interpret inpatient medical records and assess clinical validity of diagnoses and procedures
• Experience applying clinical judgment in a reimbursement or audit context