[Hiring] Clinical Quality Auditor, Senior Specialist @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a DRG/Coding Quality Auditor, Sr. Specialist who is responsible for performing on-going quality assurance audits of the accuracy and consistency of work performed by clinical and coding staff. Responsibilities include:

• Performing Outpatient Coding and DRG Validation reviews of medical records and/or other documentation.
• Validating the conditions documented in the medical record and the ICD-10-CM/PCS code assignments.
• Determining the accuracy of DRG assignment that is clinically supported.
• Accessing proprietary systems to audit medical records.
• Documenting findings and providing policy/regulatory support for determination.
• Maintaining extensive outpatient and/or inpatient coding experience.
• Holding an active coding certification with a background in auditing medical records.
• Understanding payment methodologies including MS-DRG and APR-DRG.

Qualifications

• Associates degree required; bachelor’s degree preferred.
• 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.
• 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, complications/comorbidities (CCs), and major complications/comorbidities (MCCs).
• Expert knowledge of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition in accordance with CMS requirements.
• Demonstrated ability to apply clinical review judgment to make clinical determinations.
• Excellent written communication skills.
• Advanced knowledge of medical codes, coding conventions, and rules.
• Demonstrated experience in medical review, chart audits, and quality improvement processes.

Requirements

• Perform quality assurance audits of final review outcomes.
• Identify quality trends and develop corrective interventions.
• Create educational content and lead training initiatives.
• Audit medical records for compliance with coding, regulatory, and clinical guidelines.
• Document review determinations and quality review results.
• Analyze documentation to ensure reviews are complete and accurate.
• Train, mentor, and provide feedback to new Coders and Clinical DRG Auditors.
• Maintain current coding knowledge, required CEUs, RN licensure, and coding certifications.
• Attend trainings and meetings to enhance knowledge of clinical policies.
• Cross-train across multiple claim types and specialty audits.
• Serve as a subject matter expert during business proposal activities.
• Assist with projects, data analysis, reporting, and feedback as assigned by leadership.
• Consistently meet established productivity and quality performance standards.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies.