Position SummaryThe 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 ResponsibilitiesReview 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 QualificationsAssociate'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

DRG Validator/Reviewer (CCS) - Denials / Post-Bill Inpatient Coding Review

Emma

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Language(s) required:

Ashley Long

Jeff Rubin

Ken Greene

Ashley Long

Jeff Rubin

Ken Greene

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