[Hiring] DRG Quality Advisor Nurse @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for a DRG Quality Advisor Nurse who is responsible for performing ongoing quality assurance audits, complex clinical review validation, and DRG clinical/coding audits of medical records and related documentation. This position evaluates whether review determinations align with medical records, approved clinical and coding guidelines, regulatory requirements, and contract-specific review methodologies.

• Perform quality assurance checks on final review work for complex clinical claims.
• Conduct DRG validation reviews of medical record documentation to determine the accuracy of review determinations, principal and secondary diagnoses, MCCs, CCs, procedure codes, and DRG assignment.
• Review and analyze claim data and medical record documentation using approved clinical review methodologies, coding guidelines, official coding guidance, Coding Clinic guidance, and applicable regulatory requirements.
• Apply clinical review judgment, ICD-10-CM/PCS coding expertise, and knowledge of DRG reimbursement methodologies to make accurate clinical, coding, sequencing, and validation determinations.
• Clearly and concisely document audit findings, review determinations, rationales, and supporting evidence in applicable systems.
• Demonstrate proficiency in multiple payment methodologies, including MS-DRG, AP-DRG, and APR-DRG, outpatient coding (APC/EAPG).
• Assist management with onboarding, training, mentoring, daily monitoring, feedback, and education for new reviewers, coders, or clinical DRG auditors.
• Maintain current knowledge of coding guidelines and successfully complete required CEUs to maintain RN licensure and coding certification.
• Cross-train across multiple claim types and specialty review areas to support workforce flexibility.
• Serve as a subject matter expert as needed for business proposals, projects, data analysis, reporting, feedback, and other initiatives.
• Consistently achieve productivity and quality performance standards established by management.

Qualifications

• Associates 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 with 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.
• Demonstrated proficiency in computer skills and typing, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and virtual meeting tools.

Requirements

• Home-based position with a work location within the continental United States.
• Requires a high-speed internet connection and a work environment free from distractions.
• Ability to work during normal business hours due to frequent interactions with the team and other departments.
• May require extended hours for special business needs.
• May require travel at least 10% of the time, based on business needs.
• Broadband internet should meet a minimum speed of 24 Mbps download and 8 Mbps upload to support effective telework.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.