DRG Quality Advisor Nurse- Remote
$90,000–$110,000 year
RemoteUnited States
Job Summary
Conduct ongoing quality assurance audits, complex clinical review validation, and DRG clinical/coding audits of medical records and related documentation. Evaluate review determinations against medical records, approved clinical and coding guidelines, regulatory requirements, and contract-specific review methodologies. Validate documented conditions, ICD-10-CM/PCS code assignments, DRG accuracy, and clinical support for determinations while ensuring findings are clearly documented and supported by policy, regulatory, clinical, and coding guidance. Assist management with onboarding, training, mentoring, daily monitoring, feedback, and education for new reviewers, coders, or clinical DRG auditors. Serve as a subject matter expert for business proposals, projects, data analysis, reporting, and feedback initiatives. Maintain current knowledge of coding guidelines and complete required CEUs to maintain RN licensure and coding certification. Cross-train across multiple claim types and specialty review areas to support workforce flexibility. Consistently achieve productivity and quality performance standards.
Required Qualifications
- Associates degree
- Bachelor's degree
- Active, unrestricted RN licensure in 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)
- One of the following Coding Certifications: RHIA, RHIT, CCS, CIC, CCDS, or CPC
- 5+ years clinical experience in an inpatient hospital setting
- 3+ years of MS-DRG/APR-DRG coding or auditing experience
- 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.
- Home-based position with a work location within the continental United States
- 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
Desired Qualifications
- Bachelor's degree preferred
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