Clinical DRG Auditor at HMS Healthcare

HMS Healthcare

Nurse Clinical DRG Auditor – Remote (200010TS)

HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcare—now and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.

We are seeking a talented individual for a Clinical DRG Auditor who is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical review forms, accurately documenting findings and non findings, and providing clinical/policy/regulatory support for determination.

Essential Responsibilities:

  • Reviews medical information to collect data, ensure appropriate billing of data and follow up on concerns raised by nurse and physician reviewers or other health care providers. Applies knowledge of Medicare/Medicaid rules and regulations pertaining to appropriate billing and coding of Medicare or Medicaid accounts. Applies critical review judgment to make clinical determinations of medical information reviewed.
  • Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan development and implementation as requested, both internally and with external customers.
  • Identifies and coordinates routine contract deliverables to include producing and performing quality assurance on existing client reports and contact logs and all other reports requested by internal and external customers.
  • Communicates with other health care professionals as a liaison regarding contract specifications. Relates any questions or concerns that cannot be addressed to Sr. Coding/Clinical Specialist or management for follow up. Distributes contract-specific information as appropriate; adheres to work completion due dates.
  • Assists with project data analysis, reporting, and feedback.
  • Shares ideas on clinical topics through identification of needs or concerns within the community as a result of interactions.

Non-Essential Responsibilities:

  • Performs other functions as assigned


Knowledge, Skills and Abilities:

  • Demonstrated proficiency in medical record analysis and ICD-10-CM and PCS coding methodologies.
  • Demonstrated knowledge of medical codes, coding conventions and rules.
  • Demonstrated experience in medical review, chart audits, and quality improvement processes.
  • Demonstrated experience with coding systems.
  • Demonstrated ability to apply critical review judgment to make clinical determinations.
  • Working knowledge of HIPAA Privacy and Security Rules.
  • Ability to be careful and thorough about detail.
  • Ability to analyze information and use logic to address work-related issues and problems.
  • Ability to multi-task.
  • Ability to build relationships both internally and externally.
  • Ability to demonstrate customer service and public relations skills.
  • Ability to demonstrate team process and facilitation skills.
  • Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment
  • Ability to communicate and exchange information
  • Ability to comprehend and interpret documents and data
  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
  • Requires manual dexterity to use computer, telephone and peripherals
  • May be required to work extended hours for special business needs
  • May be required to travel at least 10% of time based on business needs

Certifications: (Required/Desired)

  • Current/Active RN license required; Coding credential preferred, not required – RHIA, RHIT, CCS, CPC.

Minimum Education:

  • High School Diploma or GED required
  • Associates degree in Nursing required

Minimum Related Work Experience:

  • Minimum 3-5 years of general nursing experience – (Med/Surg, ED, ICU preferred), Inpatient coding experience preferred, or equivalent combination of education and experience.

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