DRG Reviewer

Who we Are

As a leading healthcare intelligence company with over 40 years of experience, we put our unrivaled payment integrity, subrogation, and coordination of benefits (COB) expertise, expansive perspective, and relentless focus to work for our clientsensuring no stone is left unturned in our pursuit of unmatched results. Our commitment to accuracy and excellence has helped us grow into a proven leader of our industry, relied on by companies large and small to help them maximize their return on investment.

Location: This role is full remote

About the Opportunity

At NewCo, were constantly reimagining whats possible in our industrycreating disruptively simple, powerfully clear ways to maximize our clients financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Claims team, you will, as a DRG Reviewer, be a key contributor as a DRG Reviewer responsible for conducting thorough DRG payment validation reviews, including clinical and coding assessments, of medical records and related documentation in accordance with contract-specific review criteria. This position requires an in-depth understanding of clinical guidelines, coding protocols, and regulatory requirements to ensure accurate payment determinations.

In this role, you will meticulously document findings, provide detailed clinical, policy, and regulatory support and collaborate with relevant stakeholders to ensure compliance with payment standards. Your expertise will be critical in ensuring that payment decisions are supported by accurate and complete documentation, ultimately contributing to the integrity and efficiency of the payment process.

What youll 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.

Education Requirements:
An associate or bachelors degree in nursing (active/unrestricted license); or in health information management is required.
Work experience may be considered in lieu of formal education at leadership discretion.

Certification (at least one of the following is required)
RHIA - Registered Health Information Administrator
RHIT- Registered Health Information Technician
CCDS - Certified Clinical Documentation Specialist
CDIP - Clinical Documentation Improvement Practitioner
CCS - Certified Coding Specialist
CIC - Certified Inpatient Coder

Qualifications:

• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more required

• 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.
• Expert in DRG methodologies (e.g., MS & APR).
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHAs Coding Clinic Guidelines.
• Ability to work independently and efficiently with minimal supervision.

What Success Looks Like

After 3 months

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• Youve gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

• You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• Youve been entrusted with greater responsibility indicating the companys confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $85,000-$105,000 USD

This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employees geographic location.

Whats in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

At NewCo, were reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative, accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, NewCo is making healthcare work better for everyone, and were passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. NewCo is an employment at will employer.

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