DRG Nurse Quality Auditor, Sr. Specialist

Gainwell Technologies LLC

23d•$85,000 - $99,000•Remote

About The Position

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. SummaryWe are seeking a talented individual for a DRG Nurse Quality Auditor, Sr. Specialist who is responsible for performing on-going quality assurance audits of the accuracy and consistency of work performed by clinical and coding staff. Responsibilities include performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to validate the conditions that were documented in the medical record, the ICD-10-CM/PCS code assignments and determine the accuracy of DRG assignment that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. The candidate must have extensive clinical experience and an active coding certification with a background in auditing medical records with a high level of understanding payment methodologies including MS-DRG, and APR-DRG.

Requirements

Associates degree required; bachelor’s degree preferred.
Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
One of the following Coding Certifications required: RHIA, RHIT, CCS, CIC, CCDS or CPC
5+ years clinical experience in an inpatient hospital setting required
3+ years of MS DRG/APR DRG coding or auditing experience with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
Expert knowledge of ICD -10-CM coding 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)
Expert knowledge of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.
Demonstrated ability to apply clinical review judgment to make clinical determinations
Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of review determinations.
Advanced knowledge of medical codes, coding conventions and rules.
Demonstrated experience in medical review, chart audits and quality improvement processes.

Responsibilities

Conducts QA audits to ensure accurate determinations and high-quality documentation.
Identifies quality trends and develops corrective education and training.
Reviews medical records for accurate coding, compliance, and guideline adherence.
Applies job aids, policies, and criteria consistently during reviews.
Documents review decisions clearly for reporting and trending.
Meets productivity and quality standards while completing all review elements accurately.
Supports and trains new reviewers, coders, or clinical DRG auditors as needed.
Demonstrates strong knowledge of payment methodologies, DRG validation, and client-specific requirements.
Maintains current knowledge of coding guidelines, licensure, and CEU requirements.
Participates in trainings, cross-trains on claim types, and supports projects, analysis, and reporting.
Serves as a subject matter expert as needed.