DRG Validator

Job Summary

We are seeking an experienced DRG Validator to perform inpatient coding and DRG validation reviews. This role is responsible for auditing medical records, evaluating clinical documentation, validating coded data, and ensuring accurate assignment of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG classifications. The ideal candidate has extensive inpatient coding experience, strong knowledge of reimbursement methodologies, and expertise in regulatory compliance and clinical documentation review.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records to validate coding accuracy, documentation integrity, and DRG assignment.
• Evaluate ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, MS-DRG classifications, APR-DRG assignments, severity of illness (SOI), and risk of mortality (ROM) indicators.
• Ensure compliance with Official Coding Guidelines, UHDDS requirements, CMS regulations, payer guidelines, and applicable federal and state regulations.
• Review clinical documentation to support code assignment and reimbursement accuracy.
• Utilize coding and auditing software, including 3M, TruCode, Epic, and other health information management systems.
• Prepare clear, concise, and evidence-based audit findings and validation rationales.
• Develop and submit physician documentation queries to clarify clinical documentation when appropriate.
• Analyze coding and DRG-related denials and prepare appeal letters supporting hospital reimbursement positions.
• Provide education and feedback to coding professionals regarding coding guidelines, documentation requirements, and audit outcomes.
• Recommend opportunities to improve coding accuracy, documentation quality, and DRG assignment practices.
• Stay current with coding regulations, Coding Clinic updates, CMS guidance, and reimbursement methodologies.
• Collaborate with physicians, Clinical Documentation Integrity (CDI) specialists, coders, and other healthcare professionals regarding coding and documentation issues.
• Meet established productivity, accuracy, and quality standards.

Required Qualifications

• One of the following AHIMA credentials:
  • Certified Coding Specialist (CCS)
  • Registered Health Information Technician (RHIT)
  • Registered Health Information Administrator (RHIA)
• Minimum 5 years of inpatient coding experience with ICD-10-CM/PCS.
• Minimum 5 years of experience in DRG validation, clinical validation, quality auditing, claim auditing, revenue integrity, or recovery auditing.
• Advanced knowledge of:
  • ICD-10-CM and ICD-10-PCS coding
  • MS-DRG and APR-DRG methodologies
  • Clinical documentation improvement (CDI)
  • Inpatient reimbursement systems
  • Medicare and commercial payer guidelines
• Experience reviewing medical necessity, clinical indicators, and coding compliance.
• Proficiency with Microsoft Office Suite, including Outlook, Word, Excel, PowerPoint, Teams, and SharePoint.
• Experience using coding and auditing platforms such as 3M, TruCode, Epic, and related systems.
• Strong analytical, research, written, and verbal communication skills.
• Ability to work independently while managing multiple priorities and deadlines.

Preferred Qualifications

• Experience preparing and supporting payer audit appeals.
• Knowledge of revenue cycle operations, denial management, and reimbursement methodologies.
• Prior experience providing coding education and training to coding professionals, CDI staff, and clinicians.

Skills

• Inpatient Coding
• DRG Validation
• Clinical Validation
• ICD-10-CM/PCS Coding
• MS-DRG and APR-DRG
• Medical Record Auditing
• Denials and Appeals
• Clinical Documentation Review
• Revenue Integrity
• Medicare Compliance
• Quality Assurance
• Physician Queries
• Coding Education
• Healthcare Reimbursement