HMSHost - All cities VA

Clinical DRG Auditor - Remote

Job description

It takes great medical minds to create powerful solutions that solve some of healthcare's most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you've honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you'll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.


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



The pay range for this position is $75,000.00 - $85,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You'll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.


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