DRG Reviewer

Position Purpose

Responsible for independently conducting comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement.

Requirements

• 4+ years experience of performing MS-DRG and APR-DRG coding
• In-patient and post-pay experience highly preferred
• Associate's Degree in Health Information Management, Nursing, or related field required
• 2+ years experience of performing DRG reviews for a Payment Integrity vendor or Payer
• 2+ years experience of using DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar)
• 1+ years experience of inpatient hospital documentation improvement preferred
• RHIT - Registered Health Information Technician required or RHIA - Registered Health Information Administrator Required
• Certified International Credit Professional (CICP) Required
• Certified Clinical Documentation Specialist (CCDS) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure

Qualifications

• Advanced expertise in ICD-10-CM/PCS coding
• Ability to exercise discretion and professional judgment in assessing complex clinical information
• Validating diagnosis code assignments
• Identifying discrepancies such as coding errors or upcoding
• Interpreting regulatory requirements
• Making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies
• Independently conducting comprehensive MS-DRG and APR-DRG coding and clinical validation reviews
• Collaborating with the Medical Director on complex cases
• Leading the evaluation of complex cases and proactively identifying opportunities to develop medical policy
• Evaluating claims and medical records for compliance with state and federal regulations, payer contracts, and company policies
• Preparing clear, concise, and well-supported audit findings
• Contributing to strategic initiatives by assisting in the development of audit concepts, identifying new audit opportunities, and selecting claims for review

Skills

• Advanced knowledge of coding guidelines and clinical policies
• Independent judgment in interpreting requirements and resolving ambiguities
• Compliance with all policies and standards

Benefits

Competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Centene offers a comprehensive benefits package including:

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.