Clinical Quality Auditor, Sr. Specialist - Outpatient & DRG- Remote

Summary

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 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 outpatient and/or inpatient coding experience and an active coding certification with a background in auditing medical records with a high level of understanding payment methodologies including APC/EAPG, MS-DRG, and APR-DRG.

Your role in our mission

• Performs QA audits on final review outcomes to ensure accurate determinations and high-quality documentation.
• Identifies quality trends and develops interventions, including education content and training initiatives.
• Demonstrates proficiency in MS-DRG, AP-DRG, APR-DRG, APC/EAPG outpatient coding, and client-specific review requirements.
• Interprets and applies coding guidelines, CMS regulations, NCCI edits, OPPS, EAPG, APC payment policies, and ASC reimbursement guidelines.
• Performs outpatient coding reviews and quality audits.
• Applies internal job aids, policies, and criteria sets during QA and medical record reviews.
• Provides detailed documentation of quality review results for trending and reporting.
• Reviews documentation to ensure accuracy, completeness, production goals, and quality standards are met.
• Assists management with training new reviewers through monitoring, mentoring, feedback, and education.
• Effectively trains new Coders and Clinical DRG Auditors through monitoring, mentoring, feedback, and education.
• Maintains current coding knowledge and completes required CEUs to maintain RN licensure and coding certification.
• Attends training and meetings to enhance knowledge of clinical policies, procedures, rules, and regulations.
• Cross-trains to review multiple claim types, including Place of Service, Level of Care, Readmissions, and specialty audits.
• Serves as a subject matter expert in the business proposal process.
• Assists with projects, data analysis, reporting, and feedback as assigned by leadership.
• Consistently meets productivity and quality performance standards.

What we're looking for

• 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 (EAPG/APC) 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
• Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of review determinations.
• Advanced knowledge of medical codes, coding conventions and rules.
• Demonstrated experience in medical review, chart audits and quality improvement processes.

What you should expect in this role

• Remote position
• 0-10% of travel