DRG Reviewer

About This Role

This role involves reviewing DRG assignments for hospital partners to ensure accurate reimbursement and compliance, leveraging both traditional coding expertise and advanced AI tools to streamline review workflows.

Responsibilities

• Conduct MS-DRG and APR-DRG audits for provider organizations
• Review inpatient medical records and apply ICD-10-CM/PCS coding guidelines
• Validate DRG assignments and document defensible, compliant recommendations
• Utilize proprietary AI-supported auditing tools to streamline review workflows
• Partner with audit teams on large-scale engagements and complex claim denials
• Participate in provider meetings and exit interviews to present findings
• Stay current on Official Coding Guidelines, AHA Coding Clinic updates, and regulatory changes

Requirements

• Active national certification (RHIA, RHIT, CCS, or equivalent)
• 5+ years of inpatient coding experience (IPPS environment)
• 2+ years conducting DRG validation or inpatient claims auditing
• Deep knowledge of DRG structure, coding conventions, and clinical documentation
• Ability to operate effectively in a high-volume, fast-paced setting
• Strong communication skills and sound clinical judgment

Qualifications

• 5+ years of inpatient coding experience (IPPS environment) and 2+ years conducting DRG validation or inpatient claims auditing

Nice to Have

• Experience with coding software and major EMR systems
• Background in Clinical Documentation Improvement (CDI)

Skills

* Required skills

Benefits

Certifications