DRG Dispute Reviewer

Machinify

3d•$100,000 - $115,000•Remote

About The Position

The DRG Dispute Reviewer evaluates provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. The role requires advanced knowledge of MS-DRG and APR-DRG methodologies, clinical validation, coding guidelines, and payer policies. The reviewer independently assesses medical documentation to ensure audit decisions are accurate, defensible, and compliant. The position supports regulatory compliance, overpayment identification and recovery, and appropriate documentation and reimbursement practices across healthcare systems. The reviewer analyzes inpatient records and related documentation, applies clinical and coding expertise, and prepares evidence-based rationales for determinations. The role also collaborates with audit teams, meets accuracy and productivity standards, follows privacy and ethical coding requirements, communicates with clients as needed, and uses audit platforms and coding tools. This is a digital-first, work-from-anywhere-in-the-US position.

Requirements

Associate or bachelor’s degree in nursing with an active, unrestricted license, or a degree in health information management; work experience may be considered in lieu of formal education at leadership discretion.
At least one of the following certifications: RHIA, RHIT, CCS, CIC, CDIP, or CCDS.
Minimum 3 years of inpatient hospital coding experience involving IPPS reimbursement.
Minimum 4 years of DRG validation experience, clinical and coding.
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 complex case reviews.
Ability to write clear, professional rationales supported by clinical and coding evidence.
High attention to detail, accuracy, and compliance.
Ability to work independently with minimal supervision in a remote environment.
Technical proficiency with medical record systems, audit platforms, encoder/grouper tools, and Microsoft Office Suite.

Nice To Haves

Experience in DRG dispute reviews, clinical validation, and recovery audits.
Prior experience in inpatient clinical documentation integrity (CDI).
Familiarity with encoder/grouper tools such as TruCode and 3M.

Responsibilities

Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.
Review inpatient medical records, UB-04s, and documentation for correct DRG assignment and compliance with coding, billing, and payment guidelines.
Apply clinical validation and coding principles using MS-DRG and APR-DRG grouping logic to support or overturn audit findings.
Prepare clear, concise, evidence-based rationales for determinations for clients, providers, or payers.
Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.
Assess medical necessity, documentation sufficiency, and code assignment accuracy using clinical judgment.
Collaborate with audit leads and team members to ensure consistency and quality in dispute resolutions.
Meet accuracy, timeliness, and productivity standards for dispute review and audit completion.
Follow HIPAA guidelines, industry best practices, and AHIMA’s Standards of Ethical Coding.
Participate in client meetings, including presenting audit results when required.
Use proprietary audit platforms, encoders, and medical record systems efficiently.
Perform additional tasks as assigned to support audit operations and client needs.