Clinical DRG Auditor

🕒 April 11

🤠 Texas – Remote

🤠 Texas – Remote

💵 $85k - $95k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• 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.

🎯 Requirements

• Active, unrestricted RN licensure from the United States and in the state of primary home residency • At least one of the following Coding Certifications is required and to be maintained as 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.

🏖️ Benefits

• generous, flexible vacation policy • 401(k) employer match • comprehensive health benefits • educational assistance • leadership and technical development academies