Quality Medical Auditor

Sr. Medical Review Auditor Job at a

Glance Title:

Sr.

Medical Review Auditor Location:

Columbia, SC Contract:

W2 only

Pay:

$ 36/hour + optional medical, dental, vision, 401(k) match Overview Performs validation reviews of Diagnosis Related Groups (DRG), Adaptive Predictive Coding (APC), and Never Events for all lines of business. Coordinates rate adjustments with claims areas and provides monthly and quarterly reports outlining trends, outcomes, and savings that directly impact medical costs and contracting rates. Key Responsibilities Performs validation reviews of Diagnosis Related Groups (DRG), Adaptive Predictive Coding (APC), and Never Events for all lines of business. Coordinates rate adjustments with claims areas. Provides monthly and quarterly reports outlining trends. Serves as a resource in resolving coding issues. Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department. Determines methodology to identify cases for validation review. Conducts validation reviews/coordinates rates adjustments with appropriate claims area. Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates. Manages records retrieval, release, HIPAA compliance, and all aspects of document management. Serves as expert resource on methodology and procedures for medical records and coding issues. Required Skills Develops methodologies Follows processes Responds to Inquiries Writes for Impact null Required Education Associate Degree - Nursing or Health Information Management Graduate of an Accredited School of Nursing Preferred Skills

WILL HAVE POTENTIAL FOR REMOTE WORK, BUT PREFERS ONSITE

Can live anywhere in SC or bordering NC as long as they are able to commute to the worksite location as needed. If given remote option - BCBS will provide the equipment.

License/Certification required:

a RHIT, RHIA, CIC, CPMA, or CPC should be the top search credentials (not RN or CCS).

Required Training:

Registered Records Administrator or Technician, OR, active, unrestricted RN licensure from the US and in SC OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC),

OR Certified Coder Required Work Experience:

3 years medical record management to include coding and validation review experience.

FYI:

DRG review = a review of a hospital stay to confirm the correct DRG (Diagnosis-Related Group) was assigned and billed. What's being reviewed Clinical documentation in the chart (diagnoses, procedures, complications/comorbidities, discharge summary) Coding (ICD-10 diagnosis/procedure codes) DRG assignment (the grouping produced from the codes) SOI/ROM (severity of illness / risk of mortality) when applicable Medical necessity and whether the documented facts support the level of care (often reviewed alongside DRG, depending on the program) Why it's done To ensure accurate reimbursement (DRG drives payment for many inpatient claims, e.g., Medicare IPPS) To catch undercoding (missing CC/MCC, missed procedures) or overcoding To support/defend against payer audits/denials (e.g., DRG validation audits) For compliance (reduce improper payments, improve documentation/coding accuracy) Who typically performs it Inpatient coders CDI specialists (Clinical Documentation Integrity) DRG auditors (hospital side or payer/third-party) If Why Should I Apply? Join a team expanding DRG review capacity and contribute to accurate reimbursement, compliance, and defensible coding outcomes through validation reviews and expert record/coding methodology.

About CEI:

As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements. #ZR #INDGEN