Job Description
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 HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.
Required Skills & Experience
• Must have one of the following AHIMA certifications: CCS, RHIT, or RHIA
• Extensive knowledge of medical terminology, anatomy, coding terminology and coding guidelines
for ICD-10-CM/PCS, Quality Metrics.
• Equivalent experience of 5+ years in DRG/Clinical Validation claims auditing, quality assurance or
recovery auditing.
• Minimum of 5+ years of working with ICD-10-CM/PCS, MS-DRG, and APR-DRG with a broad
knowledge of medical claims billing/payment systems, and payer reimbursement policies.
• Adherence to Official Coding Guidelines for Coding and Reporting, Coding Clinic determinations,
CMS, and other regulatory compliance guidelines and mandates which requires expert coding
knowledge of DRG, ICD-10-CM and PCS codes.
• Demonstrates basic skills in Microsoft Outlook, Word, Excel, PowerPoint, 3M, TruCode, Teams,
SharePoint, and other applications.
• Must have good written and verbal communication skills.
• Possess the ability to educate health care professionals in various settings.
• Responsible and self-sufficient with strong analytical and research skills.
• Must be able to meet or exceed deadline completion times required.
Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.