DRG Clinical Auditor

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders - internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.

Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our mission is simple: to bend the cost curve in healthcare for all.

Our commitment to service excellence extends to both internal and external stakeholders, driving us to consistently exceed expectations. We operate with intention and purpose. We foster innovation, champion diversity, nurture accountability, and empower each other to reach our collective potential.

Join us as we continue our transformational journey to become a leading voice in healthcare technology, data, and innovation.

The Senior DRG Clinical Auditor analyzes high-dollar and highly complex healthcare claims to ensure accurate billing practices and regulatory compliance.

In this role, you will apply advanced clinical knowledge, coding standards, industry expertise, and federal regulations to review itemized hospital bills and claim documentation. You will identify billing abnormalities, unbundling, questionable billing practices, and improper coding combinations, while documenting findings and denial rationale.

This role also serves as a subject matter expert, supporting clinical review teams, operational efficiency, and coding education initiatives.

• Strong working knowledge of DRG reimbursement methodology (REQUIRED)

• Review and analyze complex inpatient and outpatient charges across various revenue centers.
• Evaluate charges based on patient diagnosis, procedures, age, facility type, and related documentation.
• Perform detailed itemized bill reviews to identify unbundling, duplicate charges, improper coding combinations, and billing irregularities.
• Apply national coding standards, federal regulations, and industry best practices to claims review.
• Research and review claims, operative notes, claim trends, and itemized billing documentation.
• Document audit results and update systems accordingly.

• Ensure claim reviews comply with HIPAA regulations, reimbursement policies, and federal/state guidelines.
• Monitor coding trends, regulatory updates, and industry practices impacting claim accuracy.
• Apply clinical judgment and analytical expertise to review highly complex or escalated claims.

• Identify opportunities for cost recovery and overpayment prevention.
• Research and recommend improvements to reduce billing errors and increase operational efficiency.
• Monitor turnaround times and recommend process enhancements.

• Provide guidance to coders, negotiators, physicians, and internal teams on clinical and coding issues.
• Participate in training, mentoring, and onboarding of new and existing staff.
• Develop educational materials and job aids related to coding and claim review processes.
• Support negotiation strategies by providing coding insights and claim review findings.

• Partner with physician advisors, analytics teams, and leadership to enhance coding edits, claim factors, and reference materials.
• Communicate coding, reimbursement, and clinical findings clearly to internal teams and leadership.
• Collaborate across departments to support departmental and organizational goals.

• Assist management with operational support and departmental initiatives.
• Evaluate performance of new and existing team members when applicable.
• Demonstrate commitment to company values and organizational objectives.
• Due to exposure to Protected Health Information (PHI), this role is classified as a High Risk Role.
• Perform additional duties as assigned.

This role operates independently with minimal supervision while managing multiple complex audits simultaneously.

The Senior Clinical Auditor applies deep expertise in healthcare coding, billing practices, reimbursement models, and regulatory requirements to review claims and resolve complex billing issues. More complex cases may be escalated to senior leadership as appropriate.

The salary range for this position is $80,000 - $85,000 annually.