DRG Clinical Validation Auditor

DRG Clinical Validation Auditor Seeking a highly qualified and experienced DRG Clinical Validation Auditor to join our dynamic healthcare team. In this critical role, you will play a key role in ensuring the accuracy of patient diagnoses reflected in medical records, upholding the highest standards of quality and compliance. Job Summary The DRG Clinical Validation Auditor is responsible for conducting comprehensive reviews of medical records to verify the accuracy of DRG assignment based on clinical documentation. You will leverage your expertise in clinical documentation review and medical coding to ensure adherence relevant healthcare regulations.

Responsibilities

Conduct in-depth reviews of physician documentation to validate patient diagnoses, ensuring alignment with the clinical picture presented in medical records.

Uphold strict adherence to CMS guidelines and other relevant healthcare regulations. Demonstrate a clear understanding of the distinction between DRG clinical validation and DRG coding validation processes, recognizing the necessity for a clinician or a clinician with approved coding credentials for clinical validation.

Perform DRG clinical validation audits while adhering to established inpatient audit limits, ensuring no increase in the number of audits conducted on hospitals.

Identify and report on claims that are accurately coded but lack supporting clinical indicators, emphasizing the importance of thorough clinical validation.

Exclude hospitals with prospective rate agreements from the scope of DRG clinical validation audits.

Foster a collaborative working environment with clinicians, healthcare providers, and administrative staff to ensure the accuracy and integrity of clinical documentation. Prepare comprehensive audit reports with actionable feedback and recommendations for healthcare providers and administrative staff.

Maintain a commitment to continuous learning, staying abreast of current healthcare regulations, and industry best practices to optimize audit processes and ensure compliance.

Qualifications : Doctor of Medicine (MBBS) degree. Proven experience in clinical documentation review or medical officer. Understanding of DRG coding and clinical validation processes. Working knowledge of CMS guidelines and other relevant healthcare regulations.

Skills: Strong analytical and critical thinking skills. Meticulous attention to detail and exceptional accuracy. Excellent communication and interpersonal skills, fostering effective collaboration. Ability to thrive in both independent and team-oriented work environments. Proficiency in medical coding software and electronic health record (EHR) systems.

Preferred Qualifications Additional certification in medical coding (e.g., CPC, CCS). Prior experience in a similar auditing or clinical validation role. Strong understanding of healthcare compliance and regulatory requirements.

Job Types: Full-time, Permanent

Pay: Up to ₹800,000.00 per year

Work Location: In person