Alaffia Health
Clinical DRG Auditor
US +1 · Full-time · Posted Oct 16, 2026
- Location
- US
Remote (United States) - Experience
- 3+ years in a listed or similar clinical review or payment integrity field.
- Visa sponsorship
- Requires current authorization to work in the United States; work visa sponsorship is not available.
About the job
Conduct inpatient DRG validation audits of medical records and claims to identify unsupported diagnoses or DRG misclassification, improve payment accuracy, and inform audit automation.
What you'll do
- Review inpatient claims and documentation to validate diagnoses, procedures, sequencing, and billed DRGs against clinical and reimbursement standards.
- Document defensible audit findings, support quality assurance, and comply with HIPAA and internal procedures.
- Collaborate with operations, product, and engineering teams to improve audit processes and inform AI-driven review models.
What they ask for
- Active Registered Nurse (RN) license.
- 3+ years of experience in clinical DRG validation, inpatient clinical review, DRG auditing, CDI review, or similar payment integrity work.
- Ability to interpret inpatient medical records and assess the clinical validity of diagnoses and procedures.
- Experience applying clinical judgment in a reimbursement or audit context.
Nice to have
- Direct DRG auditing experience for payers, vendors, or consulting organizations; knowledge of inpatient reimbursement and hospital billing workflows.
- Familiarity with payer audit programs, audit platforms, EHRs, claims data systems, or a CPC, CCS, CIC, CPMA, CCDS, CDIP, or similar certification.
Tools
ICD-10-CM/PCS, MS-DRG, APR-DRG, AP-DRG, HIPAA, EHRs
AI focus
Provide clinical insight to inform audit logic and AI-driven review models.
Model-written summary · the original posting is authoritative