DRG Auditor (REMOTE)

EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations, leveraging over 24 years of industry-leading expertise and its unified E360 RCM™ intelligent automation platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers (ASCs) nationwide. Powered by proprietary algorithms, iterative intelligence from 10M+ processed claims, and expert human-in-the-loop integration, EnableComp delivers solutions across the revenue lifecycle for Veterans Administration, Workers’ Compensation, Motor Vehicle Accidents, and Out-of-State Medicaid claims as well as denials for all payer classes.

About the role

The DRG Auditor is responsible for reviewing post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Using a specialized DRG (Diagnosis-Related Group) database, DRG Auditors apply technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and make recommendations that optimize hospital reimbursement. This role requires certification as a Certified Coding Specialist (CCS) and a deep understanding of medical record documentation, clinical coding guidelines, and DRG reimbursement methodology. The position involves handling patient health information (PHI) and demands strict privacy and security protocols.

Responsibilities

• Review inpatient claims imported into the DRG database, focusing on diagnosis, procedures, grouping logic, and reimbursement accuracy
• Analyze weekly hospital billing files to identify underpaid claims based on ICD-10 diagnosis and procedure codes
• Conduct detailed medical record reviews post-bill to determine if submitted diagnosis and procedure codes are accurate and complete
• Navigate medical records efficiently, 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)
• Make 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 and identify new revenue opportunities related to all inpatient DRG components
• Perform other duties as required

Requirements

• Associate's or bachelor’s degree in health information management or related field required (RHIT or RHIA credentialed individuals encouraged)
• Certified Coding Specialist (CCS) certification required
• 2-3 years’ experience in DRG validation, inpatient medical coding, or related 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-bill 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
• Strong computer proficiency, including MS Office (Word, Excel, and Outlook)
• Ability to perform each essential duty satisfactorily; reasonable accommodations may be made for qualified individuals with disabilities

Skills

• Excellent communication and documentation skills to support client reporting and recommendations
• High integrity 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
• 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

Special Considerations

• 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