DRG Clinical Coding Validator

Job Summary:
The DRG Coding Validator integrates advanced clinical nursing knowledge with expert inpatient coding proficiency to perform comprehensive validation of Diagnosis-Related Group (DRG) assignments and associated inpatient medical record coding. Drawing on dual expertise as a Registered Nurse (RN) and a Certified Inpatient Coder (CIC or CCS), this role evaluates both the clinical validity of documented diagnoses and procedures and the accuracy of ICD-10-CM/PCS code assignments, DRG sequencing, and discharge dispositions. This position serves clients by identifying coding inaccuracies, unsupported clinical documentation, and DRG assignment errors across MS-DRG and APR-DRG reimbursement methodologies.


Why You'll Love Working at ClarisHealth


We believe our team deserves the best, and we're proud to offer a comprehensive benefits package designed to support your success, both at work and in life. Here's what you can look forward to:

• Medical, Dental, and Vision Insurance - Enjoy medical, dental, and vision insurance that begins on your first day, ensuring your health and wellness are always supported.
• 401(k) with Matching and Immediate Vesting - Secure your financial future with a company match and instant vesting.
• Company-Paid Short-Term Disability (STD) - Added security for unforeseen circumstances.
• Company-Paid Personal Financial Advising - Expert guidance to help manage your finances.
• New Hire Stipend - A one-time stipend to purchase home office supplies (laptop and charging cable provided by the company).
• Pet Insurance Options - Choose from two carrier options to keep your furry friends covered.
• Paid Holidays - 9 company holidays plus 2 floating holidays for added flexibility.
• Virtual Counseling and Telemedicine - Company-paid access to mental health and medical support from the comfort of your home.
• Paid Parental Leave - Time to focus on family during this special chapter.
• Generous Vacation & Wellness Time - 4 weeks of vacation beginning accrual on day one, plus 1 additional week for wellness.
• Professional Development Stipend - After one year, enjoy a $500 annual stipend to invest in professional growth (e.g., certifications, webinars).

Requirements:

The essential functions include, but are not limited to the following:

• Review inpatient medical records in their entirety-including history and physical, progress notes, operative reports, nursing documentation, diagnostic reports, and discharge summaries-to evaluate clinical support for reported diagnoses and procedures.
• Apply clinical nursing expertise to assess whether documented conditions meet established clinical criteria (e.g., Sepsis-3, AHA/AHIMA guidance, Coding Clinic) sufficient to support code assignment, including CC and MCC designations.
• Validate ICD-10-CM principal and secondary diagnosis code assignments, ICD-10-PCS procedure code assignments, code sequencing, present-on-admission (POA) indicators, and discharge disposition in accordance with CMS Official Guidelines for Coding and Reporting and current Coding Clinic guidance.
• Evaluate MS-DRG and APR-DRG assignment accuracy, identifying opportunities for upgrades and downgrades based on documented clinical evidence.
• Perform clinical validation reviews to distinguish between conditions that are clinically supported in the medical record versus those that are documented but lack sufficient clinical evidence.
• Investigate, review, and provide coding expertise in the application of medical and reimbursement policies within the claim adjudication process through document review.
• Perform clinical coverage review of claims, which requires interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, coding requirements, and consideration of relevant clinical information on claims with aberrant billing patterns.
• Produce clear, accurate, and concise written rationales for all validation findings, citing applicable Official Coding Guidelines, Coding Clinic references, and clinical criteria to substantiate each determination.
• Maintain and manage daily case review assignments with a high emphasis on quality.
• Provide clinical support and expertise to other investigative and analytical areas.
• Will be working in a high-volume production environment.

You may be ideal if you have:

• Active Registered Nurse (RN) licensure in the United States (compact or state-specific license accepted).
• Certified Inpatient Coder (CIC) issued by AHIMA/AACP, OR Coding and Classification Specialist (CCS) issued by AHIMA/AACP - current and in good standing.
• Minimum of 5 years of acute care inpatient hospital experience, with at least 3 years in a dedicated inpatient coding, DRG validation, or Clinical Documentation Improvement (CDI) role.
• 2+ years of experience with APR-DRG reimbursement methodologies.
• Demonstrated proficiency in ICD-10-CM/PCS code assignment, MS-DRG and APR-DRG methodologies, and CMS Official Guidelines for Coding and Reporting.
• Working knowledge of Coding Clinic guidance and ability to apply current citations to substantiate or refute code assignments.
• Comprehensive understanding of clinical validation principles, including established clinical criteria (e.g., Sepsis-3, SIRS, HAC definitions) used to evaluate the clinical legitimacy of documented diagnoses.
• Experience with clinical documentation improvement (CDI) workflows and query processes preferred.
• Intermediate to advanced proficiency with Microsoft Office Suite; experience with encoder software (e.g., Optum360, 3M, Nuance) preferred.
• Positive, self-motivated, driven, and innovative attitude.
• High standard of personal integrity and accountability.
• Passion and aptitude for solving complex problems.

This job description in no way states or implies that these are the only duties to be performed by this employee. This position will be required to follow any other instructions and to perform any other duties requested by his/her supervisor. Individuals will always be expected to maintain a professional work environment.


About ClarisHealth


ClarisHealth, based in Nashville, Tenn., provides health plans and payers with a better way to drive claims payment accuracy. Its proprietary, A.I.-powered enterprise technology platform Pareo® allows health plans across the U.S. to reduce manual work, gain insights into operational performance across lines of business, and accelerate their strategy to overpayment prevention - at a significantly reduced cost.


Company Culture


Our company values help everyone move in alignment toward this mission. We are ...

• Compassionate. We practice servant leadership, encourage inclusion and engagement, and actively acknowledge and celebrate each other's contributions.

• Communicators. We listen first with an emphasis on understanding. We seek solutions to problems, and practice radical candor with positive intent.

• Challengers. We get the right stuff done right, create clarity from complexity, take accountability and ownership, and we challenge ourselves daily.

ClarisHealth embraces a supportive working culture of creativity and innovation internally termed "Got Your Back." We live out this #GYB spirit every day by working together with team members, clients, and other partners to achieve shared goals.


For more information about ClarisHealth and our culture, please visit us at Other


Applicants must be currently authorized to work in the United States on a full-time basis. ClarisHealth is not able to sponsor applicants for work visas.


EOE, including Disability/Veterans; anyone needing accommodation to complete the interview process should notify the People Operations team