Centene
health
DRGReviewer
Neural analysis suggests this role is
optimal for Mid+ candidates.
“DRG Reviewer at Centene. Skills: MS-DRG and APR-DRG coding and clinical validation reviews, ICD-10-CM/PCS coding, DRG assignment and reimbursement accuracy, regulatory compliance, audit findings preparation. Independently conducts comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement.. Operates with significant autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and mak”
What You'll Achieve.
ensure the accuracy of DRG assignment and reimbursement; ensure compliance with all applicable laws, payer contracts, and organizational policies; ensure clinical accuracy and compliance; Consistently meets or exceeds established quality and productivity standards
Industry & Context.
exercising discretion and professional judgment in assessing complex clinical information; validating diagnosis code assignments; identifying discrepancies such as coding errors or upcoding; making authoritative decisions; making autonomous determinations regarding coding accuracy and regulatory compliance; exercising independent judgment in interpreting requirements and resolving ambiguities
What They're Looking For.
Must Have
Associate's Degree in Health Information Management, Nursing, or related field required, 4+ years experience of performing MS-DRG and APR-DRG coding required, 2+ years experience of performing DRG reviews for a Payment Integrity vendor or Payer required, 2+ years experience of using DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) required, RHIT - Registered Health Information Technician required, RHIA - Registered Health Information Administrator required, CCS-Certified Coding Specialist required, CCDS Certified Clinical Documentation Specialist required
Nice to Have
1+ years experience of inpatient hospital documentation improvement preferred, RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse or Higher (in combination with a coding credential) preferred, Certified International Credit Professional (CICP) required
What You'll Do.
Independently conducts comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement.
Operates with significant autonomy in supporting DRG validation reviews and appeals
interpreting regulatory requirements
and making authoritative decisions to ensure compliance with all applicable laws
and organizational policies.
Independently conducts comprehensive MS-DRG and APR-DRG coding and clinical validation reviews
exercising professional judgment to verify ICD-10-CM/PCS assignments
validate clinical diagnoses
identify discrepancies
and apply inpatient reimbursement rules without direct supervision.
Collaborates with the Medical Director on complex cases
providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance.
Leads the evaluation of complex cases and proactively identifies opportunities to develop medical policy in the absence of established guidelines
demonstrating discretion and authority in decision-making.
Applies advanced knowledge of coding guidelines and clinical policies throughout the review process
making autonomous determinations regarding coding accuracy and regulatory compliance.
and well-supported audit findings
referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines
approved Centene policies
and adopted clinical guidelines
ensuring recommendations reflect professional expertise.
Evaluates claims and medical records for compliance with state and federal regulations
exercising independent judgment in interpreting requirements and resolving ambiguities.
Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously.
Contributes to strategic initiatives by assisting in the development of audit concepts
identifying new audit opportunities
and selecting claims for review
demonstrating leadership in shaping audit methodologies.
Performs other duties as assigned.
Complies with all policies and standards.
How You'll Work.
Team & Collaboration
Collaborates with the Medical Director on complex cases, providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance.
Communication Scope
Prepares clear, concise, and well-supported audit findings
Full Job Description
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Responsible for independently conducting comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement. Requires advanced expertise in ICD-10-CM/PCS coding and the ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding. Operates with significant autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies. * Independently conducts comprehensive MS-DRG and APR-DRG coding and clinical validation reviews, exercising professional judgment to verify ICD-10-CM/PCS assignments, validate clinical diagnoses, identify discrepancies, and apply inpatient reimbursement rules without direct supervision. * Collaborates with the Medical Director on complex cases, providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance. * Leads the evaluation of complex cases and proactively identifies opportunities to develop medical policy in the absence of established guidelines, demonstrating discretion and authority in decision-making. * Applies advanced knowledge of coding guidelines and clinical policies throughout the review process, making autonomous determinations regarding coding accuracy and regulatory compliance. * Prepares clear, concise, and well-supported audit findings, referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelin
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