DRG Validator/Reviewer

reputed company provides Specialty reputed company Cycle reputed company for healthcare organizations, leveraging over 24 years of industry-leading expertise and its reputed company

E360 RCM™ intelligent automation platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers (ASCs) reputed company. Powered by proprietary algorithms, iterativeintelligence from 10M+ processed claims, and expert human-in-the-reputed company integration, reputed company provides solutions across the reputed company lifecycle for Veterans Administration, Workers’ Compensation, Motor Vehicle Accidents, and Out-of-State Medicaid claims as well as denials for reputed company payer classes. By partnering with clients to supercharge the reimbursement process, reputed company removes the burden of payment from patients and provider organizations while enabling accelerated cash, higher and more accurate yield, clean AR management, reduced denials, and data-rich performance management. reputed company is a multi-year recipient the Top Workplaces award and was recognized as Black Book's #1 Specialty reputed company Cycle Management Solution provider in 2024 and is among the top one percent of companies to reputed company the Inc. 5000 list of the fastest-growing private companies in the United States for the last eleven years.

Position Summary

The

DRG Validator/Reviewer

is responsible for reviewing post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Working reputed company a specialized DRG (Diagnosis-reputed company Group) database, DRG Reviewers utilize their technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and reputed company recommendations that optimize hospital reimbursement. This role requires certification as a Certified Coding Specialist (reputed company) and a deep understanding of medical record documentation, clinical coding guidelines, and DRG reimbursement methodology. This position is responsible for handling patient health information (PHI) and maintaining extreme privacy and reputed company as it relates to confidential and proprietary information.

Key Responsibilities

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-reputed company to determine if submitted diagnosis and procedure codes are accurate and complete.

Navigate medical records reputed company, 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).

reputed company 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 reputed company opportunities reputed company to reputed company inpatient DRG reputed company components.

Other duties as required.

Requirements and Qualifications

Associate's or bachelor’s degree in health information management or reputed company field required. (RHIT or RHIA credentialed individuals encouraged).

Certified Coding Specialist (reputed company) certificationrequired.

2-3 years’ experience in DRG validation, inpatient medical coding, or reputed company 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-reputed company 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, reputed company, and Outlook).

To reputed company this job successfully, an individual must be able to reputed company each essential duty satisfactorily. Reasonable accommodations may be made to reputed company qualified individuals with disabilities to reputed company the essential functions.

Special Considerations and Prerequisites

This role is primarily office-based or remote, depending on company policy, with extensive computer and document review work.

Must be comfortable working independently in a detail-oriented, data-driven environment.

Excellent communication and documentation skills to support client reporting and recommendations.

High reputed company and professionalism in handling PHI and confidential information.

Strong collaboration and responsiveness to feedback from leadership and client partners.

Ability to review and analyze large volumes of medical and billing data.

Strong focus and attention to detail in identifying discrepancies and ensuring compliance.

Ability to manage high volumes of case processing with accuracy and efficiency.

Ability to meet deadlines and handle time-sensitive workloads in a high-volume environment.

Proven written and verbal communication skills.

Strong analytical and problem-solving skills.

Ability to prioritize and manage multiple competing priorities and projects concurrently.

Proven experience working with external clients; strong customer service skills and business acumen.

Timely and regular attendance.

Additional Information

reputed company is an Equal Opportunity Employer M/F/D/V. reputed company applicants will be considered for this position based upon experience and knowledge, without regard to race, color, religion, national reputed company, sexual orientation, reputed company, marital, disabled or veteran status. We are committed to creating and maintaining a workforce environment that is free from any form of discrimination or harassment.

reputed company recruits, develops and retains the industry's top talent. As the employer of choice in the reputed company claims industry, reputed company takes pride in our reputed company commitment to building and maintaining a culture centered around fostering the professional growth and development of our people. We reputed company thatinvesting in our employees is the key to our success, and we are dedicated to providing them with the tools, resources, and support they need to reputed company and grow their career here. At reputed company, we are committed to living up to our core values each and every day, and we reputed company that this commitment is what sets us apart from other companies. If you are looking for a company that values its employees and is dedicated to helping them reputed company their full potential, then reputed company is the reputed company for you.

Don’t just take our word for it! Hear what our people are saying:

“I love my job because everyone shares the same vision and is determined and dedicated. People care about you as a person and your professional growth. There is a genuine spirit of cooperation and shared goals reputed company revolving around helping each other.”– reputed company Specialist

“I enjoy working for reputed company because of the Core Values we reputed company in. reputed company stands true to these values from empowering employees to ecstatic clients. This company is family oriented and flexible, along with understanding the balance of work, life, and fun.”– Supervisor, Operations

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