DRG Validation Specialist

• DRG Validation Specialist We are seeking a knowledgeable and detail-driven DRG Validation Specialist to ensure accuracy and compliance in diagnosis-related group (DRG) assignment and inpatient medical record coding. This role plays a key part in supporting revenue integrity, reducing audit risk, and ensuring accurate representation of patient acuity and clinical documentation.

Key Responsibilities

• Perform comprehensive DRG validation reviews on inpatient medical records to ensure accurate code assignment, clinical justification, and regulatory compliance.
• Validate ICD-10-CM, ICD-10-PCS, and sequencing accuracy to support compliant DRG assignment and reimbursement.
• Identify and address discrepancies related to clinical documentation, coding, and DRG grouping; initiate clarification queries when necessary.
• Analyze clinical indicators and documentation to ensure support for complications/co-morbidities (CCs/MCCs) and medical necessity.
• Collaborate with Coding, CDI, and Revenue Cycle teams to resolve variances and ensure alignment with documentation and reporting requirements.
• Participate in internal and external audit processes and support appeals for denied or challenged DRG assignments.
• Maintain required productivity benchmarks and exceed accuracy quality metrics (typically ≥95%).
• Stay current with changes in coding guidelines, DRG methodology, payer rules, and regulatory updates.
• Participate in training, education, special projects, and process improvement initiatives.

Qualifications

• Required certification: CCS, RHIT, RHIA, or CPC with inpatient coding experience.
• Minimum experience: 3+ years inpatient coding experience; DRG validation or audit experience strongly preferred.
• Strong working knowledge of:
• ICD-10-CM/PCS coding
• DRG payment methodologies (MS-DRG, APR-DRG, etc.)
• CMS and payer-specific audit criteria
• Prior experience with CDI programs, audit software, or EMR/EHR systems preferred.

Skills & Competencies

• Exceptional accuracy and attention to detail
• Strong critical thinking and clinical interpretation skills
• Ability to interpret complex documentation and clinical terminology
• Effective communication and collaboration across departments
• Strong organizational and time-management abilities