Billing and Coding Auditor (REMOTE)

DRG Auditor

The DRG Auditor is responsible for reviewing post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Working within a specialized DRG (Diagnosis-Related Group) database, DRG Reviewers utilize their technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and make recommendations that optimize hospital reimbursement. This role requires certification as a Certified Coding Specialist (CCS) and a deep understanding of medical record documentation, clinical coding guidelines, and DRG reimbursement methodology. This position is responsible for handling patient health information (PHI) and maintaining extreme privacy and security as it relates to confidential and proprietary information.

Review inpatient claims imported into the DRG database, focusing on diagnosis, procedures, grouping logic, and reimbursement accuracy.

Analyze weekly hospital billing files, identifying underpaid claims based on ICD-10 diagnosis and procedure codes.

Conduct detailed medical record reviews post-bill to determine if submitted diagnosis and procedure codes are accurate and complete.

Navigate medical records efficiently, targeting specific sections (e.g., discharge summary, operative reports) based on system edits and flagged items.

Match clinical documentation in the medical record to corresponding ICD-10 codes, ensuring DRG accuracy.

Utilize Health ROI system edits to detect specific high-value opportunities (e.g., dialysis, occlusion, embolization, catheterization).

Make reimbursement improvement recommendations and submit findings for client review and approval.

Stay informed on coding updates, payer guidelines, and DRG changes to support accurate recommendations.

Associate's or bachelor's degree in health information management or related field required. (Certified Coding Specialist (CCS) certification required.

• 2-3 years' 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.
• Experience working in a post-bill coding environment and familiarity with DRG grouping software and billing databases.
• Analytical thinker with a focus on financial impact and reimbursement accuracy.
• Comfortable navigating multiple digital platforms, EMRs, and data systems.
• Must have strong computer proficiency and understand how to use basic office applications, including MS Office (Word, Excel, and Outlook).
• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

This role is primarily office-based or remote, depending on company policy, with extensive computer and document review work.

Must be comfortable working independently in a detail-oriented, data-driven environment.

High integrity and professionalism in handling PHI and confidential information.

Ability to review and analyze large volumes of medical and billing data.

Ability to prioritize and manage multiple competing priorities and projects concurrently.

strong customer service skills and business acumen.

All applicants will be considered for this position based upon experience and knowledge, without regard to race, color, religion, national origin, sexual orientation, ancestry, marital, disabled or veteran status. As the employer of choice in the complex claims industry, EnableComp takes pride in our continuous commitment to building and maintaining a culture centered around fostering the professional growth and development of our people. If you are looking for a company that values its employees and is dedicated to helping them achieve their full potential, then EnableComp is the place for you.

There is a genuine spirit of cooperation and shared goals all revolving around helping each other." This company is family oriented and flexible, along with understanding the balance of work, life, and fun." Supervisor, Operations