Payment Integrity DRG Coding & Clinical Validation Analyst

The Payment Integrity DRG Coding & Clinical Validation Analyst reviews acute inpatient medical records to validate coding accuracy, DRG assignment, and physician documentation support. The role requires strong knowledge of MS-DRG and APR-DRG payment systems, ICD-10 coding, and hospital claims auditing.

Responsibilities include reviewing provider documentation for principal and secondary diagnoses, comorbidities, complications, procedures, and POA indicators; auditing acute inpatient claims; ensuring compliance with official coding guidelines and regulatory standards; and using DRG grouper, encoder, and claims processing systems to support accurate payment. The role also includes collaboration with cross-functional teams, participation in audits and payment methodology discussions, and escalating complex issues as needed.

This position has multiple levels of responsibility, with higher levels involving complex audits, mentoring, leadership, training, escalation support, and backup support for management.