DRG Reviewer

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 bachelor’s degree in nursing (active/unrestricted license); or
 Associate or bachelor’s 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 AHA’s Coding Clinic Guidelines
 Demonstrates ability to work efficiently and effectively with minimal direct supervision