Clinical Quality Auditor, Senior Specialist – Outpatient & DRG

This is a fully remote position, open to applicants in Texas.

📋 Description

• Conduct quality assurance audits on final review outcomes to guarantee accuracy in determinations and uphold high documentation standards.

• Detect quality trends, create corrective actions, develop educational materials, and spearhead training programs.

• Review medical records to confirm principal and secondary diagnoses, including MCC/CC, as well as procedure codes.

• Execute outpatient coding assessments and quality audits.

• Utilize internal job aids, policies, and criteria during quality assurance and medical record evaluations.

• Record review decisions and quality review outcomes for trending and reporting purposes.

• Assess documentation to ensure reviews are thorough, precise, and in compliance with production and quality standards.

• Train, mentor, supervise, and provide constructive feedback to new Coders, Clinical DRG Auditors, and reviewers.

• Exhibit expertise in payment methodologies, DRG mismatch resolution, pricing concerns, and client-specific review criteria.

• Stay updated with current coding knowledge, required CEUs, RN licensure, and coding certifications.

• Participate in trainings and meetings related to clinical policies, procedures, rules, and regulations.

• Cross-train across various claim types and specialty audits, such as Place of Service, Level of Care, and Readmissions.

• Act as a subject matter expert during business proposal initiatives.

• Assist with projects, data analysis, reporting, and feedback as directed by leadership.

• Achieve established productivity and quality performance benchmarks.

⛳️ Requirements

• Associate degree is mandatory; bachelor’s degree is preferred.

• Active, unrestricted RN licensure from the United States, or an unrestricted compact multistate RN license as specified by the Nurse Licensure Compact (NLC), is required.

• One of the following coding certifications is preferred: RHIA, RHIT, CCS, CIC, CPMA, CCDS, or CPC.

• A minimum of 3 years of experience in MS DRG/APR DRG coding or outpatient auditing is necessary.

• Expert-level knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies is required.

• In-depth knowledge of ICD-10-CM coding, including principal diagnosis selection, CCs, MCCs, SOI, and ROM.

• Proficient understanding of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition according to CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.

• Proven ability to apply clinical review judgment to make clinical decisions.

• Exceptional written communication skills, with the ability to craft clear, concise, accurate, and fact-based rationales.

• Advanced knowledge of medical codes, coding conventions, and regulations.

• Documented experience in medical review, chart audits, and quality improvement initiatives.

🏝️ Benefits

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

• Flexible work options.

• Career development opportunities.