DRG Validation Auditor

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care, and improving access for all. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense. We geek out over building and perfecting software that helps health plans succeed, but we also understand the irreplaceable value of human intelligence.

Role and Responsibilities

The DRG Validation Auditor is a valued member of the Penstock Audit team, responsible for reviewing inpatient claims and ensuring that the DRG paid is fair and accurate, based on the documentation in the medical record and the application of ICD-10-CM and ICD-10-PCS coding conventions, instructions, guidelines, policies, and Coding Clinic advice. The DRG Validation Auditor upholds the standards of honesty, excellence, and innovation that are central to the Penstock mission.

• Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify discrepancies between the physician documentation, the clinical picture depicted in the record, the codes billed, and the resulting DRG
• Appropriately uses industry-recognized references to support review findings, including the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics
• Writes complete, clear, and accurate rationale to support audit determinations, citing specific information from the record, and referencing appropriate guidelines, policies, regulations, and/or Coding advice

• Keeps abreast of coding, clinical, regulatory, and other industry changes that impact Penstock auditing and/or that suggest new audit opportunities
• Maintains focus on the identification and development of new audit concepts

• Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels
• Participates in focused training to learn new auditing skills across a myriad of clinical and coding scenarios
• Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate

• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers
• Serves as a Payment Integrity subject matter expert for Penstock team members and for the Goodroot organization as a whole
• Meets or exceeds Penstock’s performance and quality standards.
• Senior Auditor positions provide support for Team Lead as required.

Qualifications and Education Requirements

• Minimum of an associate degree
• Current AHIMA Health Information Management credential(s): RHIT or RHIA
• Current AHIMA/AAPC Coding Credential:  CCS or CIC
• Current Clinical Validation credential(s):  CDIP, CCDS, or CDEI
• 3 or more years of ICD-10 inpatient coding experience
• 1 or more years of clinical experience in a healthcare facility setting
• 3 or more years of auditing experience (or demonstrated equivalent)
• 1 or more years of auditing experience in a payor setting
• 1 or more years of experience in Inpatient Rehabilitation coding/auditing
• 1 or more years of experience in Inpatient Psychiatric coding/auditing
• Comprehensive understanding of ICD-10-CM Inpatient Coding Guidelines, AHA Coding Clinic, and DRG grouping mechanics
• Strong current clinical knowledgebase
• Familiarity with Clinical Documentation Integrity practices
• Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII
• Ability to conduct independent research using credible sources
• Demonstrated working knowledge of Microsoft Word, Excel, and PowerPoint
• Ability to apply critical thinking skills to record reviews
• Ability to work independently, manage workload, and adapt to shifting priorities
• Willingness to adapt and learn new auditing skills across a myriad of coding and clinical scenarios
• Excellent communication skills, both oral and written
• Comfortable working in an ever-changing fast paced environment
• Able to work Eastern time zone hours
• Secure and private home office with reliable high-speed internet connection

Preferred Skills

• Bachelor’s degree
• AHIMA/AAPC/ACDIS Auditing Credential:  Auditing: Inpatient Coding Microcredential through AHIMA, Certified Professional Medical Auditor (CPMA) through AAPC
• 5+ years of inpatient ICD-10 coding and auditing experience

• 5+ years of relevant auditing (clinical validation and medical necessity) experience

• AHIMA/AAPC Coding Certifications (RHIA, RHIT, CCS, CPC, CPC-H), AHIMA/ACDIS Clinical Documentation Certification (CDIP, CCDS), or Clinical Documentation Integrity experience
• 1-5 years of Inpatient Rehabilitation Coding/Auditing
• 1-5 years of Inpatient Psychiatric Coding/Auditing

Penstock is an affiliate company of Goodroot, which launches and grows companies dedicated to putting patients back in the center of healthcare. Penstock is an Equal Opportunity Employer. 

About Goodroot

Goodroot is a community of companies committed to delivering more access to better healthcare at a lower cost. With a growing group of brands including, but not limited to Penstock, Navion, and Emry, Goodroot is reshaping healthcare for good, one system at a time. Learn more at www.goodrootinc.com.