Clinical Quality Auditor, Senior Specialist – Outpatient & DRG

🔥 44 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $79.4k - $105k / year

⏰ Full Time

🟠 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 quality assurance audits of final review outcomes to ensure determination accuracy and high-quality documentation standards • Identify quality trends, develop corrective interventions, create educational content, and lead training initiatives • Audit medical records to validate principal and secondary diagnoses, including MCC/CC, and procedure codes • Perform outpatient coding reviews and quality audits • Apply internal job aids, policies, and criteria during QA and medical record reviews • Document review determinations and quality review results for trending and reporting • Analyze documentation to ensure reviews are complete, accurate, and meet production and quality standards • Train, mentor, monitor, and provide feedback to new Coders, Clinical DRG Auditors, and reviewers • Demonstrate expertise in payment methodologies, DRG mismatch resolution, pricing issues, and client-specific review requirements • Maintain current coding knowledge, required CEUs, RN licensure, and coding certifications • Attend trainings and meetings on clinical policies, procedures, rules, and regulations • Cross-train across multiple claim types and specialty audits, including Place of Service, Level of Care, and Readmissions • Serve as a subject matter expert during business proposal activities • Assist with projects, data analysis, reporting, and feedback as assigned by leadership • Meet established productivity and quality performance standards

🎯 Requirements

• Associate degree required; bachelor’s degree preferred • Active, unrestricted RN licensure from the United States and in the state of primary home residency, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required • One of the following coding certifications preferred: RHIA, RHIT, CCS, CIC, CPMA, CCDS or CPC • 3+ years of MS DRG/APR DRG coding or outpatient 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, 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 and ability to write clear, concise, accurate, fact-based rationales • Advanced knowledge of medical codes, coding conventions and rules • Demonstrated experience in medical review, chart audits and quality improvement processes

🏖️ Benefits

• Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Flexible work options • Career development opportunities