DRG Clinical Coding Validator
Remote
Job Summary
Review inpatient medical records in their entirety to evaluate clinical support for reported diagnoses and procedures. Validate ICD-10-CM/PCS code assignments, DRG sequencing, and discharge dispositions against CMS Official Guidelines and Coding Clinic references. Evaluate MS-DRG and APR-DRG assignment accuracy, identifying opportunities for upgrades or downgrades based on documented evidence. Produce clear written rationales for all validation findings and maintain daily case review assignments in a high-volume production environment. Provide clinical expertise to investigative and analytical areas while interpreting state and federal mandates for claims with aberrant billing patterns.
Required Qualifications
- 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
- Intermediate to advanced proficiency with Microsoft Office Suite; experience with encoder software (e.g., Optum360, 3M, Nuance)
- Positive, self-motivated, driven, and innovative attitude
- High standard of personal integrity and accountability
- Passion and aptitude for solving complex problems
- 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
Desired Qualifications
- 2+ years of experience with APR-DRG reimbursement methodologies
- Experience with clinical documentation improvement (CDI) workflows and query processes
- Intermediate to advanced proficiency with Microsoft Office Suite; experience with encoder software (e.g., Optum360, 3M, Nuance)
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.