SummaryWe 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 MS-DRG, and APR-DRG.
Your role in our mission- Perform quality assurance audits of final review outcomes to ensure determination accuracy and high-quality documentation standards.
- Identify quality trends, develop corrective interventions, create educational content, and lead training initiatives.
- Audit medical records to validate principal and secondary diagnoses (including MCC/CC) and procedure codes in compliance with coding, regulatory, and clinical guidelines.
- Perform outpatient coding reviews and quality audits.
- Apply internal job aids, policies, and criteria accurately during QA and medical record reviews.
- Clearly document review determinations and quality review results for trending and reporting.
- Analyze documentation to ensure reviews are complete, accurate, and meet production and quality standards.
- Train, mentor, monitor, and provide feedback to new Coders, Clinical DRG Auditors, and reviewers.
- Demonstrate expertise in payment methodologies, DRG mismatch resolution, pricing issues, and client-specific review requirements.
- Maintain current coding knowledge, required CEUs, RN licensure, and coding certifications.
- Attend trainings and meetings to enhance knowledge of clinical policies, procedures, rules, and regulations.
- Cross-train across multiple claim types and specialty audits, including Place of Service, Level of Care, and Readmissions.
- Serve as a subject matter expert during business proposal activities.
- Assist with projects, data analysis, reporting, and feedback as assigned by leadership.
- Consistently meet established 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 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
Applications will be accepted until October 13,2026.
The pay range for this position is $79,400.00 - $105,000.00 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.
