DRG Quality Advisor Nurse

🕒 July 29

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $90k - $110k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 33%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 checks on final review work for complex clinical claims • Conduct DRG validation reviews of medical record documentation • Determine accuracy of review determinations, principal and secondary diagnoses, MCCs, CCs, procedure codes, and DRG assignments • Review and analyze claim data and medical records using clinical methodologies, coding guidelines, Coding Clinic guidance, and regulatory requirements • Apply clinical review judgment, ICD-10-CM/PCS expertise, and DRG reimbursement knowledge • Document audit findings, review determinations, rationales, and supporting evidence • Apply MS-DRG, AP-DRG, APR-DRG, APC, and EAPG payment methodologies • Assist management with onboarding, training, mentoring, monitoring, feedback, and education • Maintain coding guideline knowledge and complete required CEUs • Cross-train across claim types and specialty review areas • Serve as a subject matter expert for proposals, projects, data analysis, reporting, and other initiatives • Meet productivity and quality performance standards

🎯 Requirements

• Associate degree required; Bachelor's degree preferred • Active, unrestricted RN licensure in the United States and in the state of primary home residency required • 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 • 5+ years clinical experience in an inpatient hospital setting required • 3+ 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, Official Guidelines for Coding and Reporting, and Coding Clinic 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 during normal business hours • Ability to work from a distraction-free home environment with high-speed internet

🏖️ Benefits

• Flexible hours • Work-life balance • Continuous learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies