Note: The job is a remote job and is open to candidates in USA. Gainwell Technologies provides healthcare technology and services that address complex healthcare challenges. The Clinical DRG Auditor performs clinical and coding validation reviews of medical records, validates ICD-10-CM/PCS code assignments and DRG accuracy, documents findings, and supports audit determinations using applicable policies and regulations.
Responsibilities
- 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. Draws on advanced ICD-10 coding expertise and clinical knowledge to substantiate conclusions. Utilizes HMS proprietary auditing systems with a high level of proficiency to document audit determinations and rationale. Applies clinical review judgment to make coding validation determinations including sequencing ICD-10-CM, ICD-10-PCS procedural codes for inpatient claims
- Consistently achieves productivity and quality performance standards established by management
- Assists management with training new Coders or Clinical DRG Auditors to include daily monitoring, mentoring, feedback and education
- Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain RN license and coding certification
- Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations
Skills
- 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
- At least one of the following Coding Certifications is required and is to be maintained as a condition of employment: RHIA, RHIT, CCS, CIC, CCDS or CPC
- 3+ years clinical experience in an inpatient hospital setting required
- 2+ 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
- Demonstrated proficiency in computer skills and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers and in virtual meeting tools i.e., Microsoft Teams, Zoom, etc
- Remote within the U.S
- May be required to work extended hours for special business needs
- Travel: 0–10% of the time, depending on business needs
Benefits
- Remote within the U.S.
- All salaried, full-time candidates are eligible for our generous, flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- A variety of leadership and technical development academies to help build your skills and capabilities
Company Overview
Company H1B Sponsorship