DRG Reviewer

Role Overview

• Responsible for independently conducting comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement
• Requires advanced expertise in ICD-10-CM/PCS coding and the ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding
• Operates with significant autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies
• Collaborates with the Medical Director on complex cases, providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance
• Prepares 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.
• Evaluates 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
• Contributes to strategic initiatives by assisting in the development of audit concepts, identifying new audit opportunities, and selecting claims for review, demonstrating leadership in shaping audit methodologies

Requirements

• Associate's Degree in Health Information Management, Nursing, or related field required
• 4+ years experience of performing MS-DRG and APR-DRG coding required
• 2+ years experience of performing DRG reviews for a Payment Integrity vendor or Payer required
• 2+ years experience of using DRG encoder/grouper (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) required
• 1+ years experience of inpatient hospital documentation improvement preferred
• RHIT
• Registered Health Information Technician required or RHIA
• Registered Health Information Administrator required or: CCS-Certified Coding Specialist required or: Certified International Credit Professional (CICP) required or: CCDS Certified Clinical Documentation Specialist required or: RN
• Registered Nurse
• State Licensure and/or Compact State Licensure Registered Nurse or Higher (in combination with a coding credential) preferred

Benefits

• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules