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.
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.
