DRG Dispute Reviewer

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

📋 Description

• Assess appeals submitted by providers and initial audit findings to confirm or amend DRG determinations.

• Examine inpatient medical records, UB-04 forms, and associated documentation to ensure proper DRG assignment and adherence to coding, billing, and payment regulations.

• Implement clinical validation and coding principles utilizing MS-DRG and APR-DRG grouping methodologies.

• Develop clear, concise, evidence-based rationales for clients, providers, or payers.

• Maintain a high level of expertise in ICD-10-CM/PCS coding standards, UHDDS definitions, and updates from the AHA Coding Clinic.

• Evaluate medical necessity, sufficiency of documentation, and accuracy of code assignments.

• Collaborate with audit leads and team members to ensure quality and consistency in dispute resolution.

• Achieve accuracy, timeliness, and productivity benchmarks.

• Comply with HIPAA regulations, industry best practices, and AHIMA’s Standards of Ethical Coding.

• Attend client meetings and present audit findings as needed.

• Utilize proprietary audit platforms, encoders, and medical record systems.

• Undertake additional responsibilities that support audit operations and client requirements.

⛳️ Requirements

• An associate or bachelor’s degree in nursing (with an active/unrestricted license) or in health information management is mandatory.

• Professional experience may be accepted in place of formal education at the discretion of leadership.

• A minimum of one certification is required: RHIA, RHIT, CCS, CIC, CDIP, or CCDS.

• At least 3 years of inpatient hospital coding experience (IPPS reimbursement) is essential.

• A minimum of 4 years in DRG validation, encompassing both clinical and coding aspects.

• Expert-level understanding of ICD-10-CM/PCS coding systems, MS-DRG/APR-DRG methodologies, and official guidelines is required.

• Strong analytical and critical thinking abilities for handling complex case reviews.

• Capability to produce clear, professional rationales supported by clinical and coding evidence.

• Exceptional attention to detail, accuracy, and compliance is necessary.

• Ability to work independently with minimal oversight in a remote setting.

• Technical skills with medical record systems and audit platforms are essential.

• Proficiency with encoder/grouper tools such as TruCode and 3M is required.

• Familiarity with Microsoft Office Suite, including Excel, Word, Outlook, and Teams is necessary.

• Experience in DRG dispute reviews, clinical validation, and recovery audits is highly preferred.

• Previous experience in inpatient clinical documentation integrity (CDI) is advantageous.

🏝️ Benefits

• Opportunity to work from anywhere in the US.

• Comprehensive Medical/Dental/Vision plans.

• Flexible Spending Account (FSA) and Health Savings Account (HSA).

• Tuition reimbursement program.

• Competitive salary package.

• 401(k) plan with company matching contributions.

• Additional health and wellness benefits, along with various perks.

• A flexible and trusting environment where you are empowered to excel in your work.

• Eligibility for quarterly bonuses.