DRG Reviewer

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

📋 Description

• Accountable for independently performing thorough reviews of MS-DRG and APR-DRG coding as well as clinical documentation to confirm the accuracy of DRG assignments and reimbursement.

• Requires advanced proficiency in ICD-10-CM/PCS coding along with the capacity to utilize discretion and professional judgment when evaluating complex clinical information, validating diagnosis code assignments, and recognizing discrepancies such as coding errors or upcoding.

• Functions with considerable autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure adherence to all relevant laws, payer contracts, and organizational policies.

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

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

• Leads the assessment of complex cases and actively seeks opportunities to develop medical policy in the absence of established guidelines, showcasing discretion and authority in decision-making.

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

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

• Assesses claims and medical records for compliance with state and federal regulations, payer contracts, and company policies, exercising independent judgment in interpreting requirements and resolving ambiguities.

• Consistently meets or surpasses established quality and productivity benchmarks while autonomously managing priorities and workflow.

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

• Performs additional duties as assigned and 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 in conducting DRG reviews for a Payment Integrity vendor or Payer is required.

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

• Preferred: At least 1 year of experience in inpatient hospital documentation improvement.

• Required: 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 combination with a coding credential) preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work approach with options for remote, hybrid, field, or office work schedules.