Inpatient DRG Reviewer
Core
Conduct post-service, pre-payment, and post-pay comprehensive inpatient DRG reviews to validate billed DRGs against medical records and coding guidelines, determining appropriate diagnosis, procedure, and discharge codes to optimize payer savings.
Role type
Inpatient DRG Reviewer / Medical Auditor
Builds
Optimized DRG claims and financial savings for healthcare payers
Domain
Healthcare administration, medical coding, insurance reimbursement
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Inpatient coding certification (CCS/CIC), ICD-10 CM/MS-DRG/APPR-DRG knowledge, readmission review evaluation, clinical evidence assessment, medical record auditing, root cause analysis, regulatory compliance (Medicare/Health Insurance)
Preferred skills
1-3 years auditing experience, hospital billing rules knowledge, productivity management
Technologies
DRG review software, medical record systems
Responsibilities
Perform comprehensive inpatient DRG validation reviews based on clinical evidence; Conduct readmission reviews to evaluate preventability and compliance; Determine and record revised Diagnosis, Procedure, and Discharge Status Codes; Regroup claims to determine new DRGs; Write customer-facing rationale statements for code changes; Document audits and upload provider communications; Identify new DRG coding concepts; Manage claims within turnaround time and productivity quotas.
Seniority
Mid-level individual contributor