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. Working within a specialized DRG (Diagnosis-Related Group) database, DRG Auditors utilize their technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and make recommendations that optimize hospital reimbursement. This role requires handling patient health information (PHI) and maintaining strict privacy and security standards.

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)

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 with a strong focus on detail
• Ability to manage high volumes of case processing with accuracy and efficiency
• Proven 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