State Licensed DRG Reviewer

Job Summary

As a key contributor to the Complex Payment Solutions Team, the remote State Licensed DRG Reviewer will conduct thorough DRG payment validation reviews, including clinical and coding assessments of medical records, ensuring compliance with contract-specific review criteria.

Key responsibilities

• Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement
• Provide evidence-based rationale for code recommendations or reconsiderations to providers or payers
• Collaborate with team leaders to ensure thorough review of DRG denials and recommend improvements to the audit system

Required qualifications

• An associate or bachelor's degree in nursing (active/unrestricted license) or health information management is required
• At least one relevant certification such as RHIA, RHIT, CCDS, CDIP, CCS, or CIC is required
• Minimum of 2 years of experience in inpatient claims auditing or Clinical Documentation Integrity
• In-depth knowledge of DRG methodologies and ICD-10-CM/PCS coding
• Ability to work independently and efficiently with minimal supervision