DRG Validator/Reviewer (REMOTE)

EnableComp • United States - Remote, TN

7d • Remote

About The Position

EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations, leveraging over 24 years of industry-leading expertise and its unified E360 RCM. The DRG Validator/Reviewer is responsible for reviewing post-billed inpatient claims to identify and validate missed reimbursement opportunities based on diagnosis and procedure coding. Working within a specialized DRG (Diagnosis-Related Group) database, DRG Reviewers utilize their technical expertise in ICD-10 coding to analyze medical records, determine coding accuracy, and make recommendations that optimize hospital reimbursement. This role requires certification as a Certified Coding Specialist (CCS) and a deep understanding of medical record documentation, clinical coding guidelines, and DRG reimbursement methodology. This position is responsible for handling patient health information (PHI) and maintaining extreme privacy and security as it relates to confidential and proprietary information.

Requirements

• Associate's or bachelor’s degree in health information management or related field required. (RHIT or RHIA credentialed individuals encouraged).
• Certified Coding Specialist (CCS) certification required.
• 2-3 years’ experience in DRG validation, inpatient medical coding, or related coding review.
• Strong understanding of ICD-10-CM/PCS coding guidelines, DRG reimbursement methodology, and hospital billing processes.
• Proficient in reading and interpreting clinical documentation across multiple departments (e.g., nursing, operative, radiology, pharmacy).
• Experience working in a post-bill coding environment and familiarity with DRG grouping software and billing databases.
• Analytical thinker with a focus on financial impact and reimbursement accuracy.
• Comfortable navigating multiple digital platforms, EMRs, and data systems.
• Must have strong computer proficiency and understand how to use basic office applications, including MS Office (Word, Excel, and Outlook).
• Ability to perform each essential duty satisfactorily.
• Must be comfortable working independently in a detail-oriented, data-driven environment.
• High integrity and professionalism in handling PHI and confidential information.
• Strong focus and attention to detail in identifying discrepancies and ensuring compliance.
• Ability to manage high volumes of case processing with accuracy and efficiency.
• Ability to meet deadlines and handle time-sensitive workloads in a high-volume environment.
• Proven written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Ability to prioritize and manage multiple competing priorities and projects concurrently.
• Proven experience working with external clients; strong customer service skills and business acumen.
• Timely and regular attendance.

Nice To Haves

• RHIT or RHIA credentialed individuals encouraged.

Responsibilities

• Review inpatient claims imported into the DRG database, focusing on diagnosis, procedures, grouping logic, and reimbursement accuracy.
• Analyze weekly hospital billing files, identifying underpaid claims based on ICD-10 diagnosis and procedure codes.
• Conduct detailed medical record reviews post-bill to determine if submitted diagnosis and procedure codes are accurate and complete.
• Navigate medical records efficiently, targeting specific sections (e.g., discharge summary, operative reports) based on system edits and flagged items.
• Match clinical documentation in the medical record to corresponding ICD-10 codes, ensuring DRG accuracy.
• Identify and correct errors such as under coded or misclassified diagnoses and procedures.
• Utilize Health ROI system edits to detect specific high-value opportunities (e.g., dialysis, occlusion, embolization, catheterization).
• Make reimbursement improvement recommendations and submit findings for client review and approval.
• Collaborate with leadership on case prioritization and workflow management.
• Stay informed on coding updates, payer guidelines, and DRG changes to support accurate recommendations.
• Analyze client reporting.
• Identify new revenue opportunities related to all inpatient DRG related components.
• Other duties as required.

Benefits

• EnableComp is an Equal Opportunity Employer M/F/D/V.
• We are committed to creating and maintaining a workforce environment that is free from any form of discrimination or harassment.
• EnableComp recruits, develops and retains the industry's top talent.
• As the employer of choice in the complex claims industry, EnableComp takes pride in our continuous commitment to building and maintaining a culture centered around fostering the professional growth and development of our people.
• We believe that investing in our employees is the key to our success, and we are dedicated to providing them with the tools, resources, and support they need to thrive and grow their career here.
• At EnableComp, we are committed to living up to our core values each and every day, and we believe that this commitment is what sets us apart from other companies.
• If you are looking for a company that values its employees and is dedicated to helping them achieve their full potential, then EnableComp is the place for you.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree