Senior DRG Auditor (Disputes)

About the role

We are seeking a Senior DRG Auditor, Disputes to join our dynamic Payment Integrity team. This critical role involves conducting comprehensive MS-DRG and APR-DRG coding reviews to ensure the accuracy of claims and maximize overpayment identification. The successful candidate will support Cohere Health’s commitment to accurate reimbursement solutions.

Responsibilities

• Conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement.
• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
• Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.
• Utilize advanced DRG encoder tools to drive efficiency and accuracy in audits.
• Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language.
• Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge.
• Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance.

Requirements

• 6 + years experience of performing MS-DRG and ARP-DRG reviews for a Payment Integrity vendor or Payer required.
• Experience with provider appeals/dispute reviews required.
• Requires advanced expertise in ICD-10-CM/PCS coding and the ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding.
• Prepares clear, concise, and well-supported audit findings, referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines, ensuring recommendations reflect professional expertise.
• An active certified coder credential (e.g., CIC, CPC, CCS, RHIA, or RHIT) required.
• CCS (Certified Coding Specialist) credential highly preferred.
• Self-motivated and able to work independently in a remote environment while maintaining high performance.
• Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously.
• Passion for DRG auditing and a commitment to teamwork, collaboration, and continuous learning.
• Excellent written and verbal communication skills, strong analytical skills, and attention to detail.
• RHIA, or RHIT credential, Associate's Degree in Health Information Management, Nursing, or related field preferred.
• Inpatient audits for case rate and per diem.
• Experience working in a start-up or high-growth company environment, demonstrating agility and adaptability.
• Familiarity with working with a diverse, global team of talent.
• Excellent computer skills and familiarity with a Mac.
• Payment Integrity audit experience preferred.

Benefits

The salary range for this position is $85,000 to $100,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment.

Interview Process

• Connect with Talent Acquisition for a Preliminary Phone Screening
• Meet your Hiring Manager!
• Case Study
• Interview with Subject Matter Expert
• Behavioral Interview(s)

About Cohere Health

Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members.

Equal Opportunity Statement

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.