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DRG Validator/Reviewer (REMOTE)
EnableComp
Remote, USA
Full-time
Entry
Remote
Discovered 1 weeks ago
Free
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- Review 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.
- Associate'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 enable qualified individuals with disabilities to perform the essential functions.
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