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.

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.

Your role in our mission:

• Perform audits of medical record documentation to determine the accuracy of principal and secondary diagnosis (including MCC & CC) and procedure codes. Adhere to official coding guidelines, coding clinics and regulatory guidelines and mandates. Draw on advanced ICD-10 coding expertise and clinical knowledge to substantiate conclusions. Utilize HMS proprietary auditing systems with a high level of proficiency to document audit determinations and rationale. Apply clinical review judgment to make coding validation determinations including sequencing ICD-10-CM, ICD-10-PCS procedural codes for inpatient claims.
• Consistently achieve productivity and quality performance standards established by management.
• Assist management with training new Coders or Clinical DRG Auditors to include daily monitoring, mentoring, feedback and education.
• Maintain current knowledge of coding guidelines and successfully complete 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

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.
•  Qualify for monthly bonuses based on production and quality.
•  May be required to work extended hours for special business needs.
•  Travel: 0–10% of the time, depending on business needs.

Sign-on bonuses are available for highly qualified candidates.

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 and visit our Careers site 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.