DRG Dispute Reviewer

The role

The DRG Dispute Reviewer evaluates provider appeals and original audit findings to determine correct DRG assignment and payment outcomes. This role uses clinical and coding expertise to assess documentation for accuracy and compliance.

What you will do

• Evaluate provider-submitted appeals and original audit findings.
• Review inpatient medical records, UB-04s, and documentation.
• Apply clinical validation and coding principles to support or overturn DRG audit findings.
• Prepare clear, concise, and evidence-based rationales.
• Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.
• Use clinical acumen to assess medical necessity and documentation sufficiency.
• Work closely with audit leads and team members.
• Meet performance standards for accuracy, timeliness, and productivity.
• Adhere to HIPAA guidelines and AHIMA’s Standards of Ethical Coding.
• Participate in client meetings and present audit results when required.

Required qualifications

• An associate or bachelor’s degree in nursing (active/unrestricted license) or in health information management.
• Work experience may be considered in lieu of formal education at leadership discretion.
• RHIA – Registered Health Information Administrator
• RHIT – Registered Health Information Technician
• CCS – Certified Coding Specialist
• CIC – Certified Inpatient Coder
• CDIP or CCDS – Clinical Documentation Improvement certification
• Minimum 3 years of inpatient hospital coding (IPPS reimbursement)
• Minimum 4 years DRG validation (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
• Ability to write clear, professional rationales

Nice to have

• Experience in DRG dispute reviews, clinical validation, and recovery audits
• Prior experience in inpatient clinical documentation integrity (CDI)

Benefits

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

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.