DRG Reviewer
Core
Independently reviews MS-DRG and APR-DRG coding and clinical documentation to ensure accurate DRG assignment and reimbursement for inpatient and post-pay claims.
Role type
Senior DRG Reviewer (Payment Integrity)
Builds
Accurate DRG assignments and compliant reimbursement determinations for payer contracts
Domain
Healthcare administration / Medical coding
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
MS-DRG and APR-DRG coding, ICD-10-CM/PCS coding, clinical documentation validation, regulatory compliance interpretation, audit findings preparation, claims evaluation, medical policy development
Preferred skills
Inpatient hospital documentation improvement, complex case leadership
Technologies
TruCode, TruBridge, 3M, Optum Encoder, Webstrat, PSI
Responsibilities
Conduct comprehensive MS-DRG and APR-DRG coding and clinical validation reviews; Collaborate with Medical Directors on complex cases; Lead evaluation of complex cases and develop medical policy; Apply advanced knowledge of coding guidelines to make autonomous determinations; Prepare clear, concise, and well-supported audit findings; Evaluate claims and medical records for compliance with regulations and contracts
Seniority
Senior, hands-on IC