Clinical Validation Auditor

Position Type: Full Time

Office Location: Remote, USA

Versalus Health is an innovative, rapidly growing organization that provides hospitals with comprehensive solutions focused on the intersection of utilization management, revenue cycle, and compliance. Versalus Health has expanded its product offering to include DRG Revenue Integrity services. By leveraging advanced analytics and DRG coding and clinical expertise, Versalus Health provides programmatic solutions for DRG coding compliance and revenue integrity. Versalus offers outstanding growth opportunities, a competitive salary and benefits package including bonuses based on individual and company performance, and reimbursement for continuing education and association dues subject to company policies. Versalus has a vibrant culture that strives to promote a positive work/life balance. Join our team and positively change healthcare!

Job Description:

The Clinical Validation Auditor utilizes data analytics and proprietary algorithms to perform prebill or post bill Clinical Validation reviews to identify documentation issues and opportunities. This position requires knowledge of MS-DRG and APR-DRG payment methodologies. The Auditor is responsible for validating ICD-10-CM/PCS codes by examining medical record documentation of clinical findings, care rendered, as well as the assignment of present on admission (POA) indicators and discharge disposition status for claims under review.

 Job Responsibilities:

  • Identifies both over and under payments. Reviews medical records and other hospital documents to validate the clinical documentation to support the assigned ICD-10-CM/PCS code assignment, selection of the principal diagnosis, and discharge disposition in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic
  • Effectively Utilizes Audit Tools. Utilizes 3M encoder and grouper software with advanced proficiency. Enters audit findings into our proprietary application accurately and in accordance with standard procedures.
  • Meets or Exceeds Standards for both Quality and Productivity set by the organization.
  • Other responsibilities as assigned. Responsibilities may be subject to change at any time at the discretion of management, formally or informally, verbally or in writing.

Knowledge, Skills & Abilities

  • Expert Clinical Validation Skills: Must possess strong clinical acumen pertaining to clinical indicators, risk factors, and treatment protocols associated with the most widely targeted principal and secondary diagnoses during payer clinical validation audits. Solid command of anatomy and physiology, diagnostic procedures, and surgical operations. Experience with multiple EHR systems such as Epic, Cerner and Meditech, etc.
  • Expert Clinical Documentation Integrity Skills: Knowledge of CDI best practice as it relates to training, education, management, process improvement and technology use. Ability to evaluate the quality of CDI queries and provide feedback to drive performance improvement.
  • Command of Inpatient Prospective Payment System (IPPS): Ability to validate MS/APR DRGs, HAC POA, and Discharge Disposition code assignments.
  • Command of ICD-10-CM/PCS Coding: Ability to validate assignment and sequencing of ICD-10-CM/PCS codes impacting reimbursement.
  • Critical Thinking. Actively and skillfully conceptualizes, applies, analyzes, synthesizes and evaluates information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to validate audit results and correct as necessary.
  • Communication Skills: Communicates clearly, proactively and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, compelling, accurate, and concise rationales in support of findings and successfully craft appeal letters with precise logic.
  • Work Independently. Is self-supporting; not needing to rely on others to complete a job.
  • Quality Orientation. Accomplishes tasks by considering all areas involved, no matter how small; shows concern for all aspects of the job; accurately checks processes and tasks; observant. Meets or exceeds both production & quality metrics assigned by the company, ensuring all rules and processes are followed.
  • PC Skills: Demonstrates proficiency in Microsoft Office (Word & Excel) and ability to problem solve Internet connectivity issues, VPN access, etc.

Education & Certification:

  • RN/RHIA/RHIT with CDIP or CCDS required. CCS highly preferred and may be required after one year of employment.
  • CDI/coding certifications, and/or professional license must be maintained as a condition of employment.

Work Experience:

  • Minimum 5 years of hospital inpatient CDI experience required.
  • DRG appeal, or recovery audit contractor, experience highly preferred.

Physical Requirements:

May be expected to sit at a desk for long hours. Repetitive movement of hands and fingers – typing and/or writing. Occasional standing, walking, stooping, kneeling or crouching. Ability to reach with hands and arms, talk and hear.

Versalus Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law.

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