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The Clinical DRG Auditor performs clinical and coding validation reviews of medical records to ensure the accuracy of DRG assignments and diagnosis coding. They also provide mentorship and training to team members while maintaining compliance with regulatory and official coding guidelines.
Requirements summary
Candidates must hold an active, unrestricted RN license and at least one professional coding certification such as RHIA, RHIT, or CCS. The role requires at least 3 years of clinical experience and 2 years of specific MS-DRG/APR-DRG auditing experience.
professional certificateMentoringMicrosoft OfficeICD-10-CMICD-10-PCSMS-DRGAP-DRGAPR-DRGMedical record auditingCoding complianceClinical reviewRegulatory guidelinesDRG validationInpatient hospital codingVirtual meeting tools
Job description
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges.
Join us and put your expertise to work in ways you never imagined possible.
We know you’ve honed your career in a fast-moving medical environment.
While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours.
And working at Gainwell carries its rewards.
You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
Sign-on bonuses are available for highly qualified candidates.
Summary
We are seeking a talented individual for a Clinical DRG Auditor who is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to validate the conditions that were documented in the medical record, the ICD-10-CM/PCS code assignments and determine the accuracy of DRG assignment that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. The candidate must have extensive clinical experience with a background in auditing medical records with a high level of understanding payment methodologies including MS-DRG, AP-DRG and APR-DRG.
What you will do
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
Benefits
Educational assistance
Sign-on bonuses
Comprehensive health benefits
401(k) employer match
Flexible vacation policy
Leadership and technical development academies
Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
What we are looking for
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.
What you should expect in this role
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.
This position is for pipeline purposes, and we welcome applications on an ongoing basis.
The pay range for this position is $90,000.00 - $105,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.
Put your passion to work at Gainwell.
You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development.
We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website [https://www.gainwelltechnologies.com/] and visit our Careers site [https://jobs.gainwelltechnologies.com/] for all available job role openings.
Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
