Role Description In this position as a Clinical DRG RN auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification. - Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance. - Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments. - Perform clinical coding review to ensure accuracy of medical coding and utilize clinical expertise and judgment to determine correct coding and billing. - Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment. - Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics. - Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly. - Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements. - Maintain and manage daily case review assignments, with a high emphasis on quality. - Provide clinical support and expertise in the other investigative and analytical areas. - Work in a high-volume production environment that is matrix driven. Qualifications - Associate’s Degree (or higher). - Unrestricted RN (Registered Nurse) license. - CCS/CIC or willing to obtain certification within 6 months of hire. - 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies. - 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM). - 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers. Preferred Qualifications - Experience with prior DRG concurrent and/or retrospective overpayment identification audits. - Experience working with Utilization Management. - Experience with readmission reviews of claims. - Experience with DRG encoder tools (ex. 3M). - Experience using Microsoft Excel with the ability to create/edit spreadsheets, use sort/filter function, and perform data entry. - Healthcare claims experience. - Managed care experience. - Knowledge of health insurance business, industry terminology, and regulatory guidelines. Soft Skills - Ability to use a Windows PC with the ability to utilize multiple applications at the same time. - Ability to work independently in a remote environment and deliver exceptional results. - Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail. - Excellent time management and work prioritization skills. Physical Requirements and Work Environment - Frequent speaking, listening using a headset, sitting, use of hands/fingers across keyboard or mouse, handling other objects, long periods working at a computer. - Have a secluded office area in which to perform job duties during the work day. - Have reliable high-speed internet access and a work environment free from distractions. Benefits - Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays. - Medical Plan options along with participation in a Health Spending Account or a Health Saving account. - Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage. - 401(k) Savings Plan, Employee Stock Purchase Plan. - Education Reimbursement. - Employee Discounts. - Employee Assistance Program. - Employee Referral Bonus Program. - Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.).

• Support medical record reviews, billing compliance audits for the Indiana Health Coverage Programs. • Evaluate quality of care, reviewing medical records and program policies and identifying compliance issues. • Prepare audit documentation and reports, and support appeals activities. • Conduct medical record and compliance reviews independently and provide preliminary findings to the Lead Reviewer. • Identify potential documentation deficiencies, and billing compliance issues. • Maintain detailed workpapers documenting procedures performed, records reviewed, findings identified, and conclusions reached. • Assist with audit responses and appeals as needed. • Ensure all work aligns with state, federal, and national healthcare and Medicaid guidelines.

• Audit and authorize reimbursement of specific and/or aggregate medical stop loss claims. • Effectively mitigate client medical stop loss claims and provide excellent customer service. • Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier. • Recognize cost mitigation opportunities. • Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits. • Initiate claims investigations and vendor referrals. • Interpret plan language, and identify experimental services and subrogation opportunities. • Identify need for follow-up on pended claims and resolution. • Communicate effectively with carriers, vendors, and management. • Provide full claims service to both phone and written inquiries. • Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history. • Develop new and review old stop loss claim forms. • Assist with internal auditing of claims auditors, and training of claims auditors.

Role Description Pro fee coder with a minimum of 3 years’ experience auditing EM and procedures across multiple specialties in particularly radiology, neuro and ortho at a trauma 1 facility. Epic experience required and Codify experience preferred. Schedule will be M-F preferably between 8am and 5 pm CST, but the start time can be flexible within reason. For the first week of training, candidates would need to be available 8a-5p CST. Qualifications - Advanced proficiency in CPT, HCPCS Level II, and ICD-10-CM coding guidelines - Strong expertise in Evaluation & Management (E/M) coding (office, hospital, consults, ED, critical care) - Extensive experience auditing procedure-based coding across multiple specialties (e.g., cardiology, orthopedics, radiology, neurosurgery, general surgery) - In-depth knowledge of NCCI edits, MUEs, modifier usage, and bundling/unbundling rules - Ability to evaluate and validate medical necessity and accurate code assignment Requirements - Proven experience auditing professional fee coding across multiple specialties, such as: - Orthopedics - Cardiology - Radiology - Neurology/Neurosurgery - General Surgery - Internal Medicine / Hospitalist - Ability to quickly interpret specialty-specific documentation and apply appropriate coding rules - Strong knowledge of CMS guidelines, payer policies, and federal/state compliance requirements - Familiarity with OIG Work Plan, audit risk areas, and regulatory updates - Experience supporting internal and external audits, including payer audits and RAC reviews - Ability to identify coding trends, compliance risks, and revenue leakage - Experience conducting retrospective and concurrent coding audits - Ability to calculate and report accuracy rates, error categorization, and financial impact - Skilled in developing audit reports, scorecards, and executive summaries - Experience creating and delivering education and feedback to coders and providers - Strong focus on continuous quality improvement and audit calibration processes - Strong understanding of clinical documentation requirements to support both E/M and procedural services - Ability to identify documentation gaps and provide actionable recommendations - Working knowledge of medical terminology, anatomy, physiology, and disease processes across specialties - Ability to clearly communicate audit findings, rationale, and coding guidelines to stakeholders - Experience collaborating with providers, coding teams, CDI, and operational leadership - Strong presentation skills for delivering education sessions and audit results - Ability to mentor and guide coders to improve quality and compliance performance Company Description Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) empowers healthcare to thrive via intelligent solutions that optimize revenue cycle operations, administrative workflows, care coordination, and clinical research on a global scale. The company works with providers, payers, life science companies, medical device manufacturers, health technology firms, researchers, and industry partners to amplify teams with robust technology, specialty expertise, and operational support. Omega Healthcare serves more than 350 healthcare organizations with 35,000 skilled workers in the United States, India, Colombia, and the Philippines.