DRG Validator/Reviewer

Position Summary

The DRG Validator/Reviewer is responsible for reviewing post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Working within a specialized DRG (Diagnosis-Related Group) database, DRG Reviewers utilize their technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and make recommendations that optimize hospital reimbursement. This role requires certification as a Certified Coding Specialist (CCS) and a deep understanding of medical record documentation, clinical coding guidelines, and DRG reimbursement methodology. This position is responsible for handling patient health information (PHI) and maintaining extreme privacy and security as it relates to confidential and proprietary information.

Key Responsibilities

• Review inpatient claims imported into the DRG database, focusing on diagnosis, procedures, grouping logic, and reimbursement accuracy.
• Analyze weekly hospital billing files, identifying underpaid claims based on ICD-10 diagnosis and procedure codes.
• Conduct detailed medical record reviews post-bill to determine if submitted diagnosis and procedure codes are accurate and complete.
• Navigate medical records efficiently, targeting specific sections (e.g., discharge summary, operative reports) based on system edits and flagged items.
• Match clinical documentation in the medical record to corresponding ICD-10 codes, ensuring DRG accuracy.
• Identify and correct errors such as under coded or misclassified diagnoses and procedures.
• Utilize Health ROI system edits to detect specific high-value opportunities (e.g., dialysis, occlusion, embolization, catheterization).
• Make reimbursement improvement recommendations and submit findings for client review and approval.
• Collaborate with leadership on case prioritization and workflow management.
• Stay informed on coding updates, payer guidelines, and DRG changes to support accurate recommendations.
• Analyze client reporting.
• Identify new revenue opportunities related to all inpatient DRG related components.
• Other duties as required.

Requirements and Qualifications

• Associate's or bachelor’s degree in health information management or related field required. (RHIT or RHIA credentialed individuals encouraged).
• Certified Coding Specialist (CCS) certification required.
• 2-3 years’ experience in DRG validation, inpatient medical coding, or related coding review.
• Strong understanding of ICD-10-CM/PCS coding guidelines, DRG reimbursement methodology, and hospital billing processes.
• Proficient in reading and interpreting clinical documentation across multiple departments (e.g., nursing, operative, radiology, pharmacy).
• Experience working in a post-bill coding environment and familiarity with DRG grouping software and billing databases.
• Analytical thinker with a focus on financial impact and reimbursement accuracy.
• Comfortable navigating multiple digital platforms, EMRs, and data systems.
• Must have strong computer proficiency and understand how to use basic office applications, including MS Office (Word, Excel, and Outlook).
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Special Considerations and Prerequisites

• This role is primarily office-based or remote, depending on company policy, with extensive computer and document review work.
• Must be comfortable working independently in a detail-oriented, data-driven environment.
• Excellent communication and documentation skills to support client reporting and recommendations.
• High integrity and professionalism in handling PHI and confidential information.
• Strong collaboration and responsiveness to feedback from leadership and client partners.
• Ability to review and analyze large volumes of medical and billing data.
• Strong focus and attention to detail in identifying discrepancies and ensuring compliance.
• Ability to manage high volumes of case processing with accuracy and efficiency.
• Ability to meet deadlines and handle time-sensitive workloads in a high-volume environment.
• Proven written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Ability to prioritize and manage multiple competing priorities and projects concurrently.
• Proven experience working with external clients; strong customer service skills and business acumen.
• Timely and regular attendance.