DRG Validator

DRG Validation Position

The DRG Validation position requires an extensive background in inpatient DRG coding with a deep understanding of the MS-DRG and APR-DRG payment systems. The validator is responsible for auditing inpatient medical records, ensuring the accuracy of coding, provider documentation, and DRG assignment.

Key Responsibilities:

• Perform concurrent and retrospective clinically based and MS-DRG and APR DRG validation reviews in compliance with appropriate coding and payments adhering to Uniform Hospital Discharge Date Set (UHDDS) and Medicare guidelines including Federal and State regulations.
• Review the correct assignment of ICD-10-CM diagnosis & ICD-10-PCS procedure codes.
• Effectively utilize facility Encoders, EMRs, abstracting systems (3M, EPIC, etc.) and auditing tools and systems (e.g., TruCode, 3M Standalone, etc.) proficiently to make audit determinations.
• Write clear, accurate, and concise rationales supporting audit findings.
• Compose physician queries for clarification of documentation.
• Provide coder education referencing applicable coding references following audits.
• Review DRG/coding denial letters and compose effectively supported appeal response letters to third party auditors and insurance carriers that summarize and support hospital position of upholding or overturning of External, PRO and/or RAC Determinations.
• Provide written recommendations for optimal coding and DRG / SOI assignment.
• Stay up to date on regulatory changes affecting coding rules and regulations.
• Maintain proficiency on the Official Coding Guidelines for Coding and Reporting and AHA Coding Clinics.
• Meets or Exceeds Standards / Guidelines for productivity maintaining production goals set by the Director of HIM Technical Services.
• Meets or Exceeds Standards / Guidelines for accuracy and quality achieving the expected level set by the Director of HIM Technical Services. Quality accuracy rate must be maintained at 95-100%.
• Able to effectively communicate with physicians, CDI staff and other clinicians regarding documentation, queries and/or coding guidelines.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to View email address on click.appcast.io.

Insight Global