Clinical DRG Auditor (Remote Nurse)

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 critical 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
• 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

• Demonstrated proficiency in medical record auditing and ICD-10-CM and 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.
• Must hold a current and valid Registered Nurse (RN) license and must have or obtain a coding credential within 1 year of hire
• Demonstrated experience in medical review, chart audits, and quality improvement processes.
• Demonstrates a thorough understanding of the APR-DRG, AP-DRG, MS-DRG, ICD-10, clinical criteria, and clinical review judgement
• 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 (work from home) environment
• Benefits on first day of employment
• Clear path advancement with training and leadership
• In order to effectively work as a teleworker with Gainwell, employees Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload.  Greater speeds will of course provide better performance.
• To Test your internet download and upload speed:
• Go to Google 
• Search for Internet Speed Test or click here.  
• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.

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