DRG Reviewer

About the Opportunity

As part of the Complex Payment Solutions Team, you will, as a DRG Reviewer, be a key contributor responsible for conducting thorough DRG payment validation reviews, including clinical and coding assessments, of medical records and related documentation in accordance with contract-specific review criteria. This position requires an in-depth understanding of clinical guidelines, coding protocols, and regulatory requirements to ensure accurate payment determinations.

In this role, you will meticulously document findings, provide detailed clinical, policy, and regulatory support, and collaborate with relevant stakeholders to ensure compliance with payment standards. Your expertise will be critical in ensuring that payment decisions are supported by accurate and complete documentation, ultimately contributing to the integrity and efficiency of the payment process.

What You'll Do

• Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement.
• Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers.
• Collaborate with team leaders to ensure thorough review of DRG denials.
• Conduct audits in alignment with organizational quality and timeliness standards.
• Use proprietary auditing systems proficiently to make consistent determinations and generate audit letters.
• Recommend improvements to the audit system to enhance efficiency.
• Ensure compliance with HIPAA regulations for protected health information.
• Perform other duties as assigned.