Senior Clinical Validation Auditor

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 AlignRx, Coeo, and Sola, Goodroot is reshaping healthcare for good, one system at a time. Our growing products and services portfolio includes pharmacy benefit consulting, pharmacy benefit coalition, health plan options for self-funded employer groups, patient navigation, and hospital financial assistance consulting. Learn more at www.goodrootinc.com. Goodroot is an Equal Opportunity Employer.

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get the 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. Named by Buffalo Business Journal as one of the best places to work!

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

Role and Responsibilities

The Clinical Validation Auditor is a key member of the Penstock team responsible for the interpretation and validation of medical record documentation to ensure billing for services is complete, accurate and follows all necessary coding and billing rules, policies, and guidelines.

• Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify clinical discrepancies in billed diagnoses and provided documentation that result in an unsupported DRG assignment, inappropriate coding or billing practices (e.g. upcoding, unbundling, investigational services, etc.), and medical necessity issues, if applicable.
• Applies critical review judgment to make clinical determinations based on documentation reviewed and codes billed using established clinical parameters and appropriate references to clinically support the billed diagnoses and procedures.
• Identifies and refers scenarios that require input from the coding team
• Completes provider appeals and conducts quality assurance reviews as required
• Develops thorough, accurate and well-documented rationale in support of determination, citing appropriate guidelines, policies, regulations, etc.
• Prepares written responses and/or participates in conference calls regarding provider disputes of audit findings.
• Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics.
• Contributes to the creation and maintenance of the Penstock Clinical Parameters library
• Identifies and communicates new or expanded audit concepts and financial recovery opportunities.
• Continuously considers the systems and processes involved with healthcare auditing (both internal and external) and communicates ideas for improvement.
• Communicates effectively with other health care and/or coding professionals, both internal and external, regarding case- or concept-specific details or questions and refers issues to management as appropriate.
• Participates in project data analysis, reporting, and feedback.
• Shares ideas on clinical or coding topics through identification of needs or concerns within the payment integrity community.
• Demonstrates a willingness to learn new clinical auditing skills and participate in auditing activities outside the scope of inpatient auditing alone.
• Meets or exceeds Penstock’s performance and quality standards.

Qualifications and Education Requirements

We are looking for candidates who share our passion for getting to the truth, and who share our commitment to improving the way healthcare is paid for.

• Associate or Bachelor’s Degree in Nursing with an active/unrestricted Registered Nurse (RN) license and 5 or more years of clinical experience in a hospital setting, OR
• Associate or Bachelor’s Degree in Health Information Management AND Active Inpatient Coding Certification AND an active credential in Clinical Documentation Improvement (CDI) with 5 or more years of recent experience in a CDI or Clinical Validation Auditor setting
• Previous recent experience in inpatient medical record reviews/auditing
• Knowledge of MS-DRG and APR-DRG methodologies
• Comprehensive understanding of inpatient hospital guidelines including coding, billing, and CMS regulations
• Demonstrated working knowledge Microsoft Word, Excel, and PowerPoint
• Comfortable working in a remote collaborative office environment
• Must be able to work the Eastern Standard Time Zone
• Able to apply analytical and critical thinking to record reviews
• Ability to work independently and manage workload/productivity expectations
• Excellent writing, editing, interpersonal, planning, teamwork, and communications skills
• Comfortable working in an ever-changing environment
• Must have access to secure, high-speed internet for a home office

Preferred Skills

• Bachelor’s degree
• 7+ years of relevant clinical auditing and/or coding experience
• AHIMA/AAPC Coding Certification (RHIA, RHIT, CCS, CPC, CPC-H)
• AHIMA/ACDIS Clinical Documentation Certification (CDIP, CCDS)

Job Type: Full-time

Pay: $95,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Experience level:

• 5 years
• 7 years

Schedule:

• Monday to Friday

Work setting:

• Remote

Education:

• Associate (Preferred)

Experience:

• Clinical Auditing or Coding: 7 years (Preferred)

License/Certification:

• AHIMA/AAPC Coding Certification (Preferred)
• AHIMA/ACDIS Clinical Documentation Certification (Preferred)

Work Location: Remote