Gainwell Technologies
DRG Nurse Quality Auditor, Sr. Specialist
Gainwell Technologies, Granite Heights, Wisconsin, United States
DRG Nurse Quality Auditor, Sr. Specialist
Join to apply for the
DRG Nurse Quality Auditor, Sr. Specialist
role at
Gainwell Technologies .
We are seeking a talented individual for a DRG Nurse Quality Auditor, Sr. Specialist who is responsible for performing ongoing 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.
What You Will Do
Conduct QA audits to ensure accurate determinations and high‑quality documentation.
Identify quality trends and develop corrective education and training.
Review medical records to validate accurate diagnosis/procedure coding and compliance with guidelines.
Apply job aids, policies, and criteria consistently during reviews.
Document review decisions clearly and provide detailed results for reporting and trending.
Ensure all review elements are completed accurately while meeting productivity and quality goals.
Support training of new reviewers through monitoring, mentoring, and feedback.
Demonstrate strong proficiency with multiple payment methodologies, DRG validation, and client‑specific requirements.
Train new Coders or Clinical DRG Auditors as needed.
Maintain up‑to‑date knowledge of coding guidelines and required licensure/CEU standards.
Participate in trainings and meetings to stay current on clinical policies and regulations.
Cross‑train on multiple claim types to support flexible workforce needs.
Serve as a subject matter expert for business proposals.
Assist with projects, data analysis, and reporting as assigned.
Consistently meet established productivity and quality standards.
What We're Looking For
Associate’s 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.
Expert knowledge of ICD‑10‑CM coding including but not limited to 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 within the U.S.
0–10% travel required.
Applications for this posting will be accepted until January 12, 2026.
The pay range for this position is $64,500.00 - $95,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job‑related knowledge, skills, and experience among other factors.
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.
Gainwell Technologies is 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), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Seniority Level
Mid‑Senior level
Employment type
Contract
Job function
Health Care Provider
Industry
IT Services and IT Consulting
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DRG Nurse Quality Auditor, Sr. Specialist
role at
Gainwell Technologies .
We are seeking a talented individual for a DRG Nurse Quality Auditor, Sr. Specialist who is responsible for performing ongoing 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.
What You Will Do
Conduct QA audits to ensure accurate determinations and high‑quality documentation.
Identify quality trends and develop corrective education and training.
Review medical records to validate accurate diagnosis/procedure coding and compliance with guidelines.
Apply job aids, policies, and criteria consistently during reviews.
Document review decisions clearly and provide detailed results for reporting and trending.
Ensure all review elements are completed accurately while meeting productivity and quality goals.
Support training of new reviewers through monitoring, mentoring, and feedback.
Demonstrate strong proficiency with multiple payment methodologies, DRG validation, and client‑specific requirements.
Train new Coders or Clinical DRG Auditors as needed.
Maintain up‑to‑date knowledge of coding guidelines and required licensure/CEU standards.
Participate in trainings and meetings to stay current on clinical policies and regulations.
Cross‑train on multiple claim types to support flexible workforce needs.
Serve as a subject matter expert for business proposals.
Assist with projects, data analysis, and reporting as assigned.
Consistently meet established productivity and quality standards.
What We're Looking For
Associate’s 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.
Expert knowledge of ICD‑10‑CM coding including but not limited to 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 within the U.S.
0–10% travel required.
Applications for this posting will be accepted until January 12, 2026.
The pay range for this position is $64,500.00 - $95,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job‑related knowledge, skills, and experience among other factors.
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.
Gainwell Technologies is 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), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Seniority Level
Mid‑Senior level
Employment type
Contract
Job function
Health Care Provider
Industry
IT Services and IT Consulting
#J-18808-Ljbffr