Clinical DRG Auditor, Specialist

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🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

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

• Perform clinical and coding DRG validation reviews of medical records and other documentation • Audit principal and secondary diagnoses, MCCs, CCs, and procedure codes for accuracy • Apply ICD-10-CM and ICD-10-PCS expertise, official coding guidelines, Coding Clinic guidance, and regulatory mandates • Use HMS proprietary auditing systems to document audit determinations, findings, rationale, and policy/regulatory support • Apply clinical review judgment to make coding validation and inpatient claim sequencing determinations • Meet productivity and quality performance standards established by management • Assist management with training, monitoring, mentoring, feedback, and education for new Coders and Clinical DRG Auditors • Maintain current knowledge of coding guidelines and complete required CEUs • Attend training and scheduled meetings

🎯 Requirements

• Active, unrestricted RN licensure from the United States and in the state of primary home residency, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) • At least one required and maintained coding certification: RHIA, RHIT, CCS, CIC, CCDS, or CPC • 3+ years of clinical experience in an inpatient hospital setting • 2+ years of MS-DRG/APR-DRG coding or auditing experience • Expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies • Expert knowledge of ICD-10-CM coding, including principal diagnosis selection, CCs, MCCs, SOI, and ROM • Expert knowledge of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition in accordance with CMS requirements and coding guidance • Demonstrated ability to apply clinical review judgment to make clinical determinations • Proficiency with Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, Microsoft Teams, Zoom, and virtual meeting tools • Ability to work extended hours for special business needs when required • Ability to travel 0–10% depending on business needs

🏖️ Benefits

• Required continuing education units (CEUs) to maintain RN license and coding certification • Training and scheduled meetings to enhance skills and working knowledge • Remote work within the U.S.