DRG Reviewer

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

📋 Description

• Conduct thorough MS-DRG and APR-DRG coding and clinical validation reviews independently.

• Confirm ICD-10-CM/PCS assignments and validate clinical diagnoses.

• Detect discrepancies in coding, such as errors or instances of upcoding.

• Implement inpatient reimbursement guidelines without direct oversight.

• Work in partnership with the Medical Director on intricate cases and provide expert recommendations.

• Assess complex cases and pinpoint opportunities for the development of medical policies.

• Utilize coding guidelines and clinical policies to ensure coding accuracy and adherence to regulations.

• Compile audit findings referencing AHA Coding Clinic, ICD-10 guidelines, Centene policies, and clinical protocols.

• Review claims and medical records to ensure compliance with regulations, payer contracts, and company policies.

• Prioritize and manage workflow independently while adhering to quality and productivity standards.

• Assist in creating audit concepts, identifying audit opportunities, and selecting claims for evaluation.

• Perform additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Minimum of 4 years of experience in MS-DRG and APR-DRG coding.

• In-patient and post-pay experience is highly desirable.

• An Associate's Degree in Health Information Management, Nursing, or a related field is required.

• At least 2 years of experience conducting DRG reviews for a Payment Integrity vendor or payer.

• A minimum of 2 years of experience using a DRG encoder/grouper such as TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar tools.

• Preferred: 1+ years of experience in inpatient hospital documentation improvement.

• One of the following certifications is required: RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), CCS (Certified Coding Specialist), CICP (Certified International Credit Professional), or CCDS (Certified Clinical Documentation Specialist).

• Preferred: RN state licensure and/or compact state licensure, or a higher registered nurse credential, in conjunction with a coding credential.

• Advanced expertise in ICD-10-CM/PCS coding.

• Familiarity with coding guidelines, clinical policies, inpatient reimbursement regulations, payer contracts, and relevant laws.

• Ability to exercise discretion and professional judgment when evaluating complex clinical information.

• Capacity to prepare clear, concise, and well-supported audit findings.

• Ability to work independently while meeting quality and productivity benchmarks.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.