Clinical DRG Auditor

March 14

🔔 Pennsylvania – Remote

Although this job is listed in Pennsylvania, this company may be open to hiring remote in other states.

💵 $59.6k - $85.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Gainwell Technologies

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Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

📋 Description

• 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. • 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 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.

🎯 Requirements

• 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 within 1 year of hire 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 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 • 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.

🏖️ Benefits

• Benefits on first day of employment • Clear path advancement with training and leadership • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies