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. 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. Operates with significant autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies.
- Independently conducts comprehensive MS-DRG and APR-DRG coding and clinical validation reviews, exercising professional judgment to verify ICD-10-CM/PCS assignments, validate clinical diagnoses, identify discrepancies, and apply inpatient reimbursement rules without direct supervision.
- 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.
- Complies with all policies and standards.
Education/Experience: 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 Licenses/Certifications: RHIT - Registered Health Information Technician required or RHIA - Registered Health Information Administrator required or: CCS-Certified Coding Specialist required or: Certified International Credit Professional (CICP) required or: 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 Pay Range: $70,100.00 - $126,200.00 per year 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. Benefits may be subject to program eligibility.