DRG Coder

Department: HS – UM | Location: 600 City Parkway West 10th Floor, Orange, CA 92868 (remote, with occasional in-person meetings)

About the role

The Senior DRG Coder reviews inpatient medical records and accurately assigns diagnosis and procedure codes using ICD-10-CM and ICD-10-PCS to determine the appropriate Diagnosis-Related Group (DRG) assignment. This role ensures coding accuracy, reimbursement integrity, and compliance with federal and state regulations, payer guidelines, and internal policies. In an Independent Practice Association (IPA) and Management Services Organization (MSO) environment, the Senior DRG Coder partners with utilization management, care management, finance, and provider network teams to support accurate payment, risk adjustment, quality reporting, and medical expense analysis.

Responsibilities

• Review inpatient hospital records and assign accurate diagnosis and procedure codes
• Determine the appropriate MS-DRG or APR-DRG assignment based on coding and clinical documentation
• Conduct coding validation and auditing to ensure compliance with payer and regulatory requirements
• Identify documentation gaps and communicate opportunities to providers, hospitals, and Clinical Documentation Improvement (CDI) teams
• Analyze denials and underpayments related to coding and DRG assignment
• Support retrospective and concurrent reviews of high-cost admissions and outlier cases
• Collaborate with utilization management, case management, finance, and contracting teams to optimize reimbursement and cost containment
• Assist with internal and external audits, including RAC, Medicare Advantage, Medicaid, and commercial payer reviews
• Provide education and mentoring to coding staff and other stakeholders
• Monitor changes in coding guidelines, reimbursement methodologies, and regulatory requirements
• Prepare reports and summaries related to coding accuracy, financial impact, and audit findings
• Maintain confidentiality and compliance with HIPAA and company policies
• Other duties as assigned

Requirements

• Associate’s degree in Health Information Management, Nursing, or related field
• At least 5 years of inpatient coding experience
• At least 2 years of advanced DRG validation, auditing, or hospital reimbursement experience
• One or more of the following certifications required:
  • CCS, RHIA, or RHIT from American Health Information Management Association
  • CIC or CPC from AAPC
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG methodologies
• Proficiency in coding software, electronic medical records, and Microsoft Office applications

Skills

• Experience working with Medicare Advantage, Medicaid, and commercial health plans
• Experience in a delegated IPA, MSO, or managed care environment
• Strong understanding of Medicare reimbursement and payer audit processes
• Ability to interpret complex clinical documentation
• Knowledge of utilization management, case management, and managed care operations
• Strong analytical, organizational, and problem-solving skills
• Ability to work independently and manage multiple priorities
• Excellent written and verbal communication skills

Pay

The national target pay range for this role is $33.00 – $38.00 per hour. Actual compensation will be determined based on geographic location, experience, and other job-related factors.