The DRG Reviewer is responsible for performing DRG payment validation (clinical/coding) reviews of medical records
and/or other documentation as defined by contract specific review criteria. This involves accurately documenting
findings and providing clinical/policy/regulatory support for payment determination.
Essential Duties and Responsibilities:
Responsible for auditing patient medical records using clinical and coding guideline knowledge along with
payer requirements to ensure reimbursement accuracy.
Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for
recommendations or reconsiderations of unsupported billed codes.
Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.
Perform all audits in observance of organizational quality and timeliness standards set by the audit
operations management team.
Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound
and consistent audit determinations and generate audit letters.
Makes recommendations for improvements to the audit system that enhance efficiency.
Assures HIPAA compliance for protected health information.
Other duties as assigned.
Job Requirements:
Education (required)
? Associate or bachelors degree in nursing (active/unrestricted license); or
? Associate or bachelors degree in health information management; or
? Work experience may be considered in lieu of formal education at leadership discretion
Certification (at least one of the following is required)
? RHIA – Registered Health Information Administrator; or
? RHIT- Registered Health Information Technician; or
? CCDS Certified Clinical Documentation Specialist; or
? CDIP Clinical Documentation Improvement Practitioner; or
? CCS – Certified Coding Specialist; or
? CPC-H, Certified Professional Coder-H (Hospital Based); or
? CIC, Certified Inpatient Coder
Experience
? Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required
? Inpatient Clinical Documentation Integrity experience of 2 years or more required
? Exhibits high standards for quality and attention to detail
? Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
? Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations
? Solid knowledge and understanding of clinical criteria and documentation requirements to successfully
substantiate code assignments
? Subject matter expert in DRG methodologies (e.g., MS & APR)
? Subject matter expert in ICD-10-CM/PCS coding methodologies, UHDDS definitions, Official Coding
Guidelines and AHAs Coding Clinic Guidelines
? Demonstrates ability to work efficiently and effectively with minimal direct supervision
