DRG Coder

Astrana Health, Inc.•Orange, CA

2d•$33 - $38•Remote

About The Position

The Senior DRG Coder is responsible for reviewing inpatient medical records and accurately assigning diagnosis and procedure codes using ICD-10-CM and ICD-10-PCS to determine the appropriate Diagnosis-Related Group (DRG) assignment. This role ensures coding accuracy, reimbursement integrity, and compliance with federal and state regulations, payer guidelines, and internal policies. In an Independent Practice Association (IPA) and Management Services Organization (MSO) environment, the Senior DRG Coder partners with utilization management, care management, finance, and provider network teams to support accurate payment, risk adjustment, quality reporting, and medical expense analysis.

Requirements

Associate’s degree in Health Information Management, Nursing, or related field
Minimum of 5 years of inpatient coding experience
Minimum of 2 years of advanced DRG validation, auditing, or hospital reimbursement experience
One or more of the following required: CCS, RHIA, or RHIT from American Health Information Management Association; CIC or CPC from AAPC
Have advanced knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG methodologies
Proficiency in coding software, electronic medical records, and Microsoft Office applications

Nice To Haves

Experience working with Medicare Advantage, Medicaid, and commercial health plans
Experience in a delegated IPA, MSO, or managed care environment
Have a strong understanding of Medicare reimbursement and payer audit processes
Ability to interpret complex clinical documentation
Knowledge of utilization management, case management, and managed care operations
Strong analytical, organizational, and problem-solving skills
Ability to work independently and manage multiple priorities
Excellent written and verbal communication skills.

Responsibilities

Review inpatient hospital records and assign accurate diagnosis and procedure codes
Determine the appropriate MS-DRG or APR-DRG assignment based on coding and clinical documentation
Conduct coding validation and auditing to ensure compliance with payer and regulatory requirements
Identify documentation gaps and communicate opportunities to providers, hospitals, and Clinical Documentation Improvement (CDI) teams
Analyze denials and underpayments related to coding and DRG assignment
Support retrospective and concurrent reviews of high-cost admissions and outlier cases
Collaborate with utilization management, case management, finance, and contracting teams to optimize reimbursement and cost containment
Assist with internal and external audits, including RAC, Medicare Advantage, Medicaid, and commercial payer reviews
Provide education and mentoring to coding staff and other stakeholders
Monitor changes in coding guidelines, reimbursement methodologies, and regulatory requirements
Prepare reports and summaries related to coding accuracy, financial impact, and audit findings
Maintain confidentiality and compliance with HIPAA and company policies
Other duties as assigned