DRG Nurse Quality Auditor, Sr. Specialist - Remote in US

Summary

We are seeking a talented individual for a DRG Nurse 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 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 and an active coding certification with a background in auditing medical records with a high level of understanding payment methodologies including MS-DRG, and APR-DRG.

Your role in our mission

• Performs quality assurance audits on final review outcomes to ensure accuracy of determination and that documentation meets high quality standards.
• Participates in identifying quality trends and developing appropriate interventions to remediate clinical opportunities.  This includes developing education content and leading training initiatives as needed.
• 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.
• Analyzes and reviews documentation to ensure all aspects of the review have been addressed properly and accurately while maintaining production goals and quality standards.
• Demonstrates high proficiency in reviewing multiple payment methodologies, solving DRG mismatch and pricing issues and pivots seamlessly to a variety of client specific review requirements.
• Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain RN license and coding certification
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs including Place of Service, Level of Care, Readmissions and other specialty audits.
• 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.

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 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

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position.
  • Monday through Friday work schedule (40 hours per week).
• Upward career advancement is possible and encouraged.
• Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
• Company match 401K and other benefits available within months of starting.
• Computer for work company-provided.
• For all hybrid and remote positions 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.  
• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.

This position is intended for pipelining. We will accept applications on an ongoing basis.

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