SummaryWe are seeking a talented individual for a DRG Quality Advisor Nurse who is responsible for performing ongoing quality assurance audits, complex clinical review validation, and DRG clinical/coding audits of medical records and related documentation. This position evaluates whether review determinations align with medical records, approved clinical and coding guidelines, regulatory requirements, and contract-specific review methodologies. The role includes validating documented conditions, ICD-10-CM/PCS code assignments, DRG accuracy, and clinical support for determinations while ensuring all findings are clearly documented and supported by policy, regulatory, clinical, and coding guidance. This position requires strong clinical expertise, advanced auditing experience, and inpatient and outpatient coding knowledge to support accurate quality review outcomes and contribute to continuous improvement across Coding and DRG review processes.
Your role in our mission- Perform quality assurance checks on final review work for complex clinical claims and conduct DRG validation reviews of medical record documentation to determine the accuracy of review determinations, principal and secondary diagnoses, MCCs, CCs, procedure codes, and DRG assignment.
- Review and analyze claim data and medical record documentation using approved clinical review methodologies, coding guidelines, official coding guidance, Coding Clinic guidance, and applicable regulatory requirements.
- Apply clinical review judgment, ICD-10-CM/PCS coding expertise, and knowledge of DRG reimbursement methodologies to make accurate clinical, coding, sequencing, and validation determinations.
- Clearly and concisely document audit findings, review determinations, rationales, and supporting evidence in applicable systems, including documentation needed for trending, reporting, and business needs.
- Demonstrate proficiency in multiple payment methodologies, including MS-DRG, AP-DRG, and APR-DRG, outpatient coding (APC/EAPG), while adapting to client-specific review requirements.
- Assist management with onboarding, training, mentoring, daily monitoring, feedback, and education for new reviewers, coders, or clinical DRG auditors.
- Maintain current knowledge of coding guidelines and successfully complete required CEUs to maintain RN licensure and coding certification.
- Cross-train across multiple claim types and specialty review areas to support workforce flexibility and meet client and business needs.
- Serve as a subject matter expert as needed for business proposals, projects, data analysis, reporting, feedback, and other initiatives as determined by department leadership.
- Consistently achieve productivity and quality performance standards established by management.
What we're looking for- Associates degree required; Bachelor's degree preferred.
- Active, unrestricted RN licensure in the United States and in the state of primary home residency, required; 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.
- Demonstrated proficiency in computer skills and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, and virtual meeting tools, i.e., Microsoft Teams, Zoom, etc.
What you should expect in this role- Home-based position with a work location within the continental United States.
- Requires a high-speed internet connection and a work environment free from distractions.
- Ability to work during normal business hours due to frequent interactions with the team and other departments.
- May require extended hours for special business needs.
- May require travel at least 10% of the time, based on business needs.
- Broadband internet should meet a minimum speed of 24 Mbps download and 8 Mbps upload to support effective telework.
The application period will remain open until September 4, 2026.
The pay range for this position is $90,000.00 - $110,000.00 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.
