Nurse Coder DRG Auditor III

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Nurse Coder DRG Auditor III based in United States.

This role serves as a subject matter expert in clinical coding, claims auditing, and payment integrity.

You will independently audit inpatient and outpatient claims using coding and clinical guidelines alongside supporting medical documentation.

The position combines clinical expertise with advanced coding validation, quality assurance, and appeal response responsibilities.

You will evaluate diagnoses, procedures, sequencing, discharge statuses, and levels of care to identify accurate and compliant claim outcomes.

The role also provides opportunities to influence coding standards, develop new concepts, and contribute to strategic recommendations.

Strong collaboration with internal teams and, when needed, clients will be essential to communicating audit findings effectively.

This is an analytical, high-impact position for an experienced RN and coding professional who can operate independently and guide others.

Accountabilities

• Independently perform DRG and APC validation using applicable coding and clinical guidelines.
• Review medical records to validate principal and secondary diagnoses, diagnosis sequencing, discharge statuses, and procedures.
• Evaluate short-stay claims to determine whether the documentation supports the medical necessity of an inpatient level of care.
• Apply CPT, ICD-10, CMS, commercial payer, InterQual, MCG, and applicable organizational policies, procedures, and regulations.
• Conduct independent audits of inpatient and outpatient claims and communicate findings clearly.
• Prepare responses to claim appeals using industry standards and applicable client and organizational policies.
• Independently validate and quality-check work completed by other team members.
• Establish and communicate coding guidelines and best practices for others to apply consistently.
• Support management with enterprise-level recommendations and strategic decision-making.
• Assist with the development of new audit concepts, methodologies, and claim selection criteria.
• Support itemized bill reviews and validation activities as needed.
• Communicate with clients when necessary to explain and support audit findings.
• Maintain all required professional licenses, certifications, continuing education, and other compliance requirements.
• Contribute to additional projects and related duties as assigned to support business and operational objectives.

Requirements

• Active RN professional license in good standing.
• Relevant clinical practice experience.
• Current coding certification in good standing, such as CCS or CIC.
• Demonstrated experience in coding validation, claims auditing, or payment integrity.
• Strong understanding of CPT and ICD-10 coding guidelines and clinical documentation.
• Ability to interpret medical records and apply coding, clinical, regulatory, and payer-specific guidelines accurately.
• Strong verbal and written communication skills, with the ability to clearly document findings and recommendations.
• Excellent organization and attention to detail, particularly when reviewing complex claims and medical documentation.
• Ability to independently prioritize multiple tasks and manage workload effectively.
• Proficiency with Microsoft Office, particularly Excel.
• Experience with appeals, APR-DRG, client communication, concept development, claim selection, or quality assurance is a plus.
• Experience in machine learning or artificial intelligence applied to healthcare or payment integrity is a plus.
• Case Management, Utilization Review, Clinical Documentation Improvement, or itemized bill validation experience is a plus.
• Previous management or leadership experience is a plus.
• RHIA or RHIT certification is a plus.
• Experience with TruCode/TruBridge, 3M, WebStrat, or similar coding and auditing platforms is a plus.
• Ability to perform sustained analytical work involving detailed reading, concentration, data review, and continuous verbal and written communication.
• Ability to work effectively in a computer-based environment and perform the repetitive typing and computer activities required for the role.
• Willingness to complete applicable compliance requirements associated with the position, which may include background or other legally permitted screening processes.

Benefits

• Competitive salary and comprehensive compensation package.
• Health insurance and other valued healthcare benefits.
• 401(k) retirement plan with employer matching.
• Paid parental leave.
• Collaborative and innovative work environment.
• Opportunity to operate as a subject matter expert and influence coding and auditing practices.
• Exposure to complex clinical coding, payment integrity, claims auditing, and healthcare compliance initiatives.
• Opportunities to contribute to strategic recommendations, new concept development, and process improvement.
• Professional growth through continuing education, certification maintenance, and cross-functional collaboration.
• Reasonable accommodations available for qualified individuals with disabilities in accordance with applicable laws.