Inpatient DRG Validator (Acute Care)
Core
Auditing inpatient medical records and generating high-quality recoverable claims by evaluating coding and DRG assignment accuracy for acute care hospitals.
Role type
Senior IC medical audit specialist (DRG validation)
Builds
Validated medical claims and audit findings letters for insurance payers
Domain
Healthcare administration and medical billing
Required skills
ICD-10 coding, MS-DRG/AP-DRG/APR-DRG analysis, clinical guidelines interpretation, medical record auditing, claims recovery identification, audit tool utilization
Preferred skills
Vendor-based DRG coding experience, hospital coding environment familiarity, payer reimbursement policy knowledge, plan policy negotiation
Technologies
ICD-9/10CM, MS-DRG, AP-DRG, APR-DRG, audit workflow systems
Responsibilities
Analyze and audit claims by integrating medical chart coding principles and clinical guidelines; Utilize audit tools to make determinations and generate audit findings letters; Identify new claim types such as re-admissions and Inpatient to Outpatient conversions; Suggest process improvement and efficiency recommendations for claim concepts.