DRG Nurse Quality Auditor, Sr. Specialist - Remote in US

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.

Summary

We 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.

Your role in our mission

• Performs quality assurance audits on final review outcomes to ensure accuracy of determination and that documentation meets high quality standards.
• Participates in identifying quality trends and developing appropriate interventions to remediate clinical opportunities.  This includes developing education content and leading training initiatives as needed.
• Performs audits of medical record documentation to determine the accuracy of principal and secondary diagnosis (including MCC & CC) and procedure codes. Adheres to official coding guidelines, coding clinics and regulatory guidelines and mandates.
• Analyzes and reviews documentation to ensure all aspects of the review have been addressed properly and accurately while maintaining production goals and quality standards.
• Demonstrates high proficiency in reviewing multiple payment methodologies, solving DRG mismatch and pricing issues and pivots seamlessly to a variety of client specific review requirements.
• Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain RN license and coding certification
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs including Place of Service, Level of Care, Readmissions and other specialty audits.
• 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.

What we're looking for

• 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