DRG Validation Specialist

DRG Validation Specialist

The DRG Validation Specialist requires extensive experience in inpatient DRG coding and a thorough understanding of the MS-DRG and APR-DRG reimbursement systems. This role is responsible for auditing inpatient medical records to ensure the accuracy of coding, clinical documentation, and DRG assignment while maintaining compliance with applicable coding guidelines and regulatory requirements.

Key Responsibilities

• Perform concurrent and retrospective clinical, MS-DRG, and APR-DRG validation reviews in accordance with UHDDS, Medicare guidelines, and applicable federal and state regulations.
• Review and validate ICD-10-CM diagnosis and ICD-10-PCS procedure code assignments.
• Utilize EMRs, encoders, abstracting systems (e.g., 3M, Epic) and auditing tools (e.g., TruCode, 3M Standalone) to perform accurate audit determinations.
• Prepare clear, concise, and well-supported audit rationales.
• Draft physician queries to obtain documentation clarification when appropriate.
• Provide coding education and feedback based on audit findings.
• Review coding and DRG denial letters and prepare well-supported appeal responses to third-party auditors and insurance carriers.
• Develop written recommendations to optimize coding accuracy and DRG/SOI assignment.
• Stay current on regulatory updates, Official Coding Guidelines, AHA Coding Clinic guidance, and reimbursement changes.
• Meet or exceed established productivity, quality, and accuracy standards, maintaining a quality accuracy rate of 95100%.
• Communicate effectively with physicians, CDI specialists, coders, and other clinical staff regarding documentation and coding guidelines.

Qualifications

• AHIMA certification required (CCS, RHIT, or RHIA).
• Minimum of 5 years of experience in inpatient DRG validation, clinical validation, quality assurance, recovery auditing, or a related field.
• Minimum of 5 years of hands-on experience with ICD-10-CM/PCS, MS-DRG, and APR-DRG coding.
• Extensive knowledge of medical terminology, anatomy and physiology, ICD-10-CM/PCS coding guidelines, CPT coding, modifiers, and payer reimbursement methodologies.
• Expert understanding of Official Coding Guidelines, Coding Clinic guidance, CMS regulations, and other applicable compliance standards.
• Proficiency with Microsoft Office applications (Outlook, Word, Excel, PowerPoint), Microsoft Teams, SharePoint, and industry-standard coding platforms including 3M and TruCode.
• Strong written and verbal communication skills.
• Excellent analytical, research, and critical thinking abilities.
• Ability to educate physicians, coders, and healthcare professionals on coding and documentation best practices.
• Self-motivated with the ability to manage priorities and consistently meet deadlines.

Position Details

• Full-time
• Remote
• Standard 8-hour workday

Nesco Resource offers a comprehensive benefits package for our associates, which includes a MEC (Minimum Essential Coverage) plan that encompasses Medical, Vision, Dental, 401K, and EAP (Employee Assistance Program) services. Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.