DRG Reviewer

About the role

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time.

Responsibilities

• Independently conducts comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement.
• Exercises discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding.
• Supports DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies.
• Collaborates with the Medical Director on complex cases, providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance.
• Leads the evaluation of complex cases and proactively identifies opportunities to develop medical policy in the absence of established guidelines, demonstrating discretion and authority in decision-making.
• Applies advanced knowledge of coding guidelines and clinical policies throughout the review process, making autonomous determinations regarding coding accuracy and regulatory compliance.
• Prepares clear, concise, and well-supported audit findings, referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines, approved Centene policies, and adopted clinical guidelines, ensuring recommendations reflect professional expertise.
• Evaluates claims and medical records for compliance with state and federal regulations, payer contracts, and company policies, exercising independent judgment in interpreting requirements and resolving ambiguities.
• Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously.
• Contributes to strategic initiatives by assisting in the development of audit concepts, identifying new audit opportunities, and selecting claims for review, demonstrating leadership in shaping audit methodologies.
• Performs other duties as assigned.

Requirements

• Associate's Degree in Health Information Management, Nursing, or related field required
• 4+ years experience of performing MS-DRG and APR-DRG coding required
• 2+ years experience of performing DRG reviews for a Payment Integrity vendor or Payer required
• 2+ years experience of using DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) required
• 1+ years experience of inpatient hospital documentation improvement preferred

Qualifications

• RHIT - Registered Health Information Technician required or RHIA - Registered Health Information Administrator Required
• Certified International Credit Professional (CICP) Required
• CCDS Certified Clinical Documentation Specialist required or RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse or Higher (in combination with a coding credential) preferred

Skills

• Advanced expertise in ICD-10-CM/PCS coding
• Ability to exercise discretion and professional judgment in assessing complex clinical information
• Discretion and authority in decision-making
• Knowledge of coding guidelines and clinical policies
• Independent judgment in interpreting requirements and resolving ambiguities

Benefits

Centene offers a comprehensive benefits package including: 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.

Pay

$70,100.00 - $126,200.00 per year