Job Summary

Join Optum, a global leader in health care innovation, as a Clinical DRG RN Auditor. You will leverage your expert knowledge of MS-DRG/APR-DRG coding and reimbursement methodologies, ICD-10 Official Coding Guidelines, and AHA Coding Clinic to audit inpatient claims. Your focus will be validating diagnosis and procedure codes, DRG assignments, and discharge statuses to identify overpayments and ensure compliance. This role offers remote work flexibility and the opportunity to impact health equity on a broad scale. A $10,000 sign-on bonus is available for external applicants.

Key Responsibilities

Conduct detailed MS-DRG and APR-DRG coding reviews to verify DRG assignment accuracy and reimbursement
Validate ICD-10-CM/PCS codes, sequencing, POA, and discharge disposition per CMS, ICD-10 Official Guidelines, and AHA Coding Clinic
Apply clinical expertise and coding knowledge to ensure accurate medical coding and billing
Write clear, concise rationales supporting audit findings based on official coding guidelines
Utilize proprietary workflow systems and encoder tools (e.g., 3M) to efficiently process claims
Stay current on coding guideline updates, reimbursement trends, and client-specific processes
Manage daily case review assignments in a high-volume, matrix-driven environment
Provide clinical support to investigative and analytical teams

Required Qualifications

Associate’s degree or higher
Active, unrestricted RN license
CCS or CIC certification or willing to obtain within 6 months of hire
Minimum 3 years MS-DRG/APR-DRG coding experience in hospital settings
Minimum 2 years ICD-10-CM and ICD-10-PCS coding experience with expertise in principal diagnosis, CC/MCC, SOI, ROM, and PCS structural components
Strong written/verbal communication, analytical, and time management skills
Ability to work independently in a remote environment
Reliable high-speed internet and a distraction-free home office

Preferred Qualifications

Experience with DRG overpayment identification audits, utilization management, readmission reviews
Experience with DRG encoder tools such as 3M
Proficiency in Microsoft Excel for data management
Knowledge of health insurance claims and managed care industry

Benefits & Incentives

$10,000 sign-on bonus for external applicants only
Comprehensive medical, dental, vision, life, disability, and retirement benefits
Paid time off plus 8 paid holidays
401(k) Savings Plan with employer match and employee stock purchase plan
Education reimbursement, employee discounts, referral bonuses, and more

Equal Employment Opportunity

UnitedHealth Group is an Equal Opportunity Employer committed to diversity and inclusion. All qualified applicants will be considered without regard to protected characteristics. Drug testing required prior to employment.

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Clinical DRG RN Auditor