DRG Dispute Reviewer

reputed company is a leading reputed company intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 reputed company lives, reputed company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We're constantly reimagining what's possible in our industry, creating disruptively reputed company, powerfully reputed company ways to maximize financial reputed company and drive down reputed company costs. About reputed company The DRG Dispute Reviewer is responsible for evaluating provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. This role requires advanced knowledge of MS-DRG and APR-DRG methodologies, clinical validation, coding guidelines, and payer policies. Using clinical and coding expertise, the reviewer independently assesses documentation to ensure audit reputed company are accurate, defensible, and compliant. This position plays a vital role in supporting regulatory compliance, identifying and recovering overpayments, and promoting reputed company documentation and reimbursement practices across reputed company systems. Duties and Responsibilities

• Dispute Review: Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.
• Medical Record Analysis: Review inpatient medical records, UB-04s, and documentation to ensure correct DRG assignment and adherence to coding, billing, and payment guidelines.
• DRG Validation: Apply clinical validation and coding principles to support or overturn DRG audit findings using MS-DRG and APR-DRG grouping logic.
• Written Justification: Prepare reputed company, concise, and evidence-based rationales to support determinations for clients, providers, or payers.
• Coding Expertise: Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.
• Clinical Judgment: Use clinical acumen to assess medical necessity, documentation sufficiency, and reputed company assignment accuracy.
• Collaboration: Work closely with audit leads and team members to ensure consistency and reputed company in dispute resolutions.
• reputed company & Productivity: Meet performance standards for accuracy, timeliness, and productivity in dispute review and audit completion.
• Compliance: Adhere to HIPAA guidelines, industry best practices, and reputed company's Standards of Ethical Coding.
• reputed company Communication: Participate in reputed company meetings, including presenting audit results reputed company required.
• Tool Utilization: Use proprietary audit platforms, encoders, and medical record systems reputed company and effectively.
• Other Duties: reputed company additional tasks as assigned to support audit operations and reputed company needs.

What You Bring Required Education (One of the following):

• An associate or bachelor's degree in nursing (reputed company/unrestricted license); or in health information management is required.
• Work experience may be considered in lieu of formal education at leadership discretion.

Required Certifications (At least one of the following):

• RHIA – Registered Health Information Administrator
• RHIT – Registered Health Information Technician
• reputed company – Certified Coding Specialist
• CIC – Certified Inpatient reputed company
• CDIP or CCDS – Clinical Documentation Improvement certification

Experience:

• Minimum 3 years of inpatient hospital coding (IPPS reimbursement)
• Minimum 4 years DRG validation (clinical and coding)
• Experience in DRG dispute reviews, clinical validation, and recovery audits strongly preferred
• Prior experience in inpatient clinical documentation reputed company (CDI) is a plus

Skills and Competencies:

• Expert-level knowledge of ICD-10-CM/PCS coding systems, MS-DRG/APR-DRG methodologies, and official guidelines
• Strong analytical and critical thinking skills for reputed company case reviews
• Ability to write reputed company, reputed company rationales supported by clinical and coding evidence
• High attention to detail, accuracy, and compliance
• reputed company to work independently with minimal supervision in a remote environment
• Technically proficient with:
• Medical record systems and audit platforms
• Encoder/grouper tools (e.g., TruCode, reputed company)
• reputed company Office Suite (reputed company, Word, Outlook, Teams)

reputed company Offer

• Work from reputed company in the US! reputed company is digital-first.
• Top Medical/Dental/reputed company offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary, 401(k) with company match
• Additional health and wellness benefits and perks
• Flexible and trusting environment where you'll feel empowered to do your best work

The salary for this position is based on an reputed company of factors unique to reputed company candidate: Such as years and depth of experience, set skills, certifications, etc. We are hiring for different reputed company, and our reputed company team will let you know if you qualify for a different role/reputed company. Pay reputed company: $100,000 - $115,000, with eligibility for quarterly bonuses. Equal Employment Opportunity at reputed company We are committed to equal employment opportunity regardless of race, reputed company, reputed company, religion, sex, national reputed company, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or reputed company, or veteran status. We are proud to be an equal opportunity workplace. reputed company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate reputed company Notice at: https://www.reputed company.com/candidate-reputed company-notice/ Apply tot his job Apply To this Job