DRG Reviewer

The role

You will conduct DRG payment validation reviews including clinical and coding assessments of medical records. You will audit patient records, provide evidence-based rationale for code recommendations, and collaborate with stakeholders to ensure compliance with payment standards.

What you will do

• Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement.
• Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers.
• Collaborate with team leaders to ensure thorough review of DRG denials.
• Conduct audits in alignment with organizational quality and timeliness standards.
• Use proprietary auditing systems proficiently to make consistent determinations and generate audit letters.
• Recommend improvements to the audit system to enhance efficiency.
• Ensure compliance with HIPAA regulations for protected health information.
• Perform other duties as assigned.

Required qualifications

• An associate or bachelor’s degree is required
• RN – Registered Nurse (active/unrestricted license) or RHIA – Registered Health Information Administrator or RHIT – Registered Health Information Technician or CCDS – Certified Clinical Documentation
• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more.
• Strong focus on quality and attention to detail.
• Deep curiosity and analytical skills to understand root causes of events and behaviors.
• Proven ability to apply critical judgment in clinical and coding determinations.
• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
• Expertise in DRG methodologies (e.g., MS & APR), ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.
• Ability to work independently and efficiently with minimal supervision.

Nice to have

• Nursing degree
• Health information management degree
• Experience with readmission and/or short-stay reviews
• Familiarity with InterQual and/or MCG (Milliman) criteria

Benefits

• Top Medical/Dental/Vision offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary
• 401(k) with company match
• PTO
• Additional health and wellness benefits and perks
• Meaningful equity

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. It uses an AI-powered platform to maximize financial outcomes and drive down healthcare costs.