DRG Reviewer

The company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

As part of the Complex Payment Solutions Team, you will, as a DRG Reviewer, be a key contributor responsible for conducting thorough DRG payment validation reviews, including clinical and coding assessments, of medical records and related documentation in accordance with contract-specific review criteria. This position requires an in-depth understanding of clinical guidelines, coding protocols, and regulatory requirements to ensure accurate payment determinations.

In this role, you will meticulously document findings, provide detailed clinical, policy, and regulatory support and collaborate with relevant stakeholders to ensure compliance with payment standards. Your expertise will be critical in ensuring that payment decisions are supported by accurate and complete documentation, ultimately contributing to the integrity and efficiency of the payment process.

What you’ll do

• Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement.

• Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers.

• Collaborate with team leaders to ensure thorough review of DRG denials.

• Conduct audits in alignment with organizational quality and timeliness standards.

• Use proprietary auditing systems proficiently to make consistent determinations and generate audit letters.

• Recommend improvements to the audit system to enhance efficiency.

• Ensure compliance with HIPAA regulations for protected health information.

• Perform other duties as assigned.

What you bring (Role Requirements)

Education Requirements

• An associate or bachelor’s degree is required (in nursing or in health information management is preferred).

• Work experience may be considered in lieu of formal education at leadership discretion.

License / Certification (at least one of the following is required)

• RN – Registered Nurse (active/unrestricted license)

• RHIA – Registered Health Information Administrator

• RHIT – Registered Health Information Technician

• CCDS – Certified Clinical Documentation Specialist

• CDIP – Clinical Documentation Improvement Practitioner

• CCS – Certified Coding Specialist

• CIC – Certified Inpatient Coder

Qualifications

• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more.

• Strong focus on quality and attention to detail.

• Deep curiosity and analytical skills to understand root causes of events and behaviors.

• Proven ability to apply critical judgment in clinical and coding determinations.

• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.

• Expertise in DRG methodologies (e.g., MS & APR), ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.

• Experience with readmission and/or short-stay reviews, and/or familiarity with InterQual and/or MCG (Milliman) criteria, is a plus.

• Ability to work independently and efficiently with minimal supervision.

What We Offer

• Work from anywhere in the US! The company is digital-first.

• Top Medical/Dental/Vision offerings

• FSA/HSA

• Tuition reimbursement

• Competitive salary, 401(k) with company match

• PTO

• Additional health and wellness benefits and perks

• Flexible and trusting environment where you’ll feel empowered to do your best work

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc.  We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range.  Salary is one component of the total compensation package, which includes meaningful equity, excellent healthcare, flexible time off, and other benefits and perks.

Pay range: $90,000 - $115,000, plus quarterly bonus.

Equal Employment Opportunity at the company

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. The company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at:  [link for members]