DRG Validation Coding Auditor

Responsibilities

• Review acute inpatient records to assess whether documented conditions, procedures, and assigned DRGs are accurately supported by the medical record.
• Analyze coding outcomes for compliance with official inpatient coding guidance, payer-specific reimbursement methodologies, and applicable regulatory standards.
• Investigate discrepancies that may affect payment accuracy, including potential underpayments, overpayments, and unsupported code assignment within retrospective claim reviews.
• Prepare clear audit findings that explain recommended revisions, citing relevant coding authorities and clinical rationale for each conclusion.
• Possess strong knowledge of ICD-10 coding guidelines, DRG assignment methodology, reimbursement principles, and medical necessity documentation review.
• Use auditing platforms, encoders, and internal workflow tools to complete reviews efficiently while meeting turnaround expectations and quality benchmarks.
• Maintain commitment to maintaining required certifications, ongoing education, confidentiality standards, and productivity expectations.

Requirements

• At least 5 years of coding experience, including substantial inpatient coding exposure.
• Minimum of 3 years of hospital or facility coding audit experience, preferably in DRG validation or related inpatient audit work.
• Strong knowledge of ICD-10 coding guidelines, DRG assignment methodology, reimbursement principles, and medical necessity documentation review.
• Ability to interpret complex inpatient records and apply coding, clinical, and compliance standards with accuracy and consistency.
• Proficiency with coding software, encoder applications, and Microsoft Office tools.
• Effective written and verbal communication skills with the ability to deliver concise, well-supported audit feedback.
• Bachelor’s degree or equivalent combination of education and relevant experience.

Qualifications

Commitment to maintaining required certifications, ongoing education, confidentiality standards, and productivity expectations.