EnableComp provides specialty revenue cycle management solutions for healthcare organizations, supporting hospitals, health systems, and ambulatory surgery centers nationwide.
The DRG Validator/Reviewer reviews post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Working within a specialized DRG database, the role uses ICD-10 expertise to analyze medical records, assess coding accuracy, and make recommendations that improve hospital reimbursement.
Key responsibilities include:
- Review inpatient claims imported into the DRG database, focusing on diagnosis, procedures, grouping logic, and reimbursement accuracy
- Analyze weekly hospital billing files to identify underpaid claims based on ICD-10 diagnosis and procedure codes
- Conduct detailed post-bill medical record reviews to confirm diagnosis and procedure code accuracy and completeness
- Navigate medical records efficiently and locate relevant documentation such as discharge summaries and operative reports
- Match clinical documentation to corresponding ICD-10 codes to ensure DRG accuracy
- Identify and correct undercoded or misclassified diagnoses and procedures
- Use system edits to detect high-value opportunities such as dialysis, occlusion, embolization, and catheterization
- Prepare reimbursement improvement recommendations for client review and approval
- Collaborate with leadership on case prioritization and workflow management
- Stay current on coding updates, payer guidelines, and DRG changes
- Analyze client reporting and identify new revenue opportunities related to inpatient DRG components
- Perform other duties as assigned
Requirements & Qualifications
- Associate's or bachelor's degree in health information management or a related field required; RHIT or RHIA credentialed individuals encouraged
- Certified Coding Specialist (CCS) certification required
- 2-3 years of experience in DRG validation, inpatient medical coding, or related coding review
- Strong understanding of ICD-10-CM/PCS coding guidelines, DRG reimbursement methodology, and hospital billing processes
- Ability to read and interpret clinical documentation across departments such as nursing, operative, radiology, and pharmacy
- Experience in a post-bill coding environment and familiarity with DRG grouping software and billing databases
- Strong analytical skills with a focus on financial impact and reimbursement accuracy
- Comfortable working across digital platforms, EMRs, and data systems
- Proficiency with Microsoft Word, Excel, and Outlook
- Strong communication, documentation, problem-solving, and time-management skills
- Ability to work independently in a detail-oriented, data-driven environment
- Proven experience working with external clients and maintaining professionalism when handling PHI and confidential information
Location
Tennessee, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
4 weeks ago