DRG Reviewer

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

📋 Description

• Accountable for independently executing thorough assessments of MS-DRG and APR-DRG coding along with clinical documentation to guarantee the precision of DRG classification and reimbursement.

• Requires advanced proficiency in ICD-10-CM/PCS coding and the capability to apply discretion and professional judgment when evaluating intricate clinical data, confirming diagnosis code assignments, and detecting inconsistencies such as coding errors or upcoding.

• Operates with considerable independence in facilitating DRG validation reviews and appeals, interpreting regulatory stipulations, and making decisive judgments to ensure adherence to all relevant laws, payer agreements, and organizational policies.

• Conducts detailed MS-DRG and APR-DRG coding and clinical validation reviews autonomously, applying professional judgment to verify ICD-10-CM/PCS assignments, validate clinical diagnoses, identify discrepancies, and implement inpatient reimbursement guidelines without direct oversight.

• Collaborates with the Medical Director on intricate cases, offering expert recommendations and influencing review results to assure clinical accuracy and compliance.

• Leads the assessment of complex cases and proactively seeks opportunities to establish medical policy in the absence of defined guidelines, exhibiting discretion and authority in decision-making.

• Utilizes advanced knowledge of coding principles and clinical policies during the review process, making independent determinations regarding coding accuracy and regulatory compliance.

• Compiles clear, concise, and well-supported audit findings, referencing authoritative materials such as AHA Coding Clinic and ICD-10 guidelines, approved Centene policies, and accepted clinical guidelines to ensure recommendations reflect professional expertise.

• Assesses claims and medical records for compliance with state and federal regulations, payer contracts, and company policies, utilizing independent judgment to interpret requirements and resolve uncertainties.

• Consistently achieves or surpasses defined quality and productivity benchmarks while managing priorities and workflow independently.

• Contributes to strategic initiatives by aiding in the development of audit concepts, identifying new audit prospects, and selecting claims for review, showcasing leadership in shaping audit methodologies.

• Performs additional duties as assigned.

• Adheres to all policies and standards.

⛳️ Requirements

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

• A minimum of 4 years of experience in MS-DRG and APR-DRG coding is required.

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

• 2 years of experience using DRG encoder/grouper software (such as TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) is required.

• Preferably, 1 year of experience in inpatient hospital documentation improvement.

• Must possess RHIT - Registered Health Information Technician or RHIA - Registered Health Information Administrator, or CCS - Certified Coding Specialist, or Certified International Credit Professional (CICP), or CCDS - Certified Clinical Documentation Specialist, or RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse or higher (in conjunction with a coding credential) is preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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