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.
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.
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.
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
DRG Validation Specialist • Nashville, TN, US
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