[Hiring] DRG Reviewer @Centene Corporation

Role Description

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.

• 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 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, payer contracts, and company policies, 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.

Qualifications

• 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.
• 1+ years experience of inpatient hospital documentation improvement preferred.

Requirements

• RHIT - Registered Health Information Technician required or
• RHIA - Registered Health Information Administrator required or
• CCS-Certified Coding Specialist required or
• Certified International Credit Professional (CICP) required or
• CCDS Certified Clinical Documentation Specialist required or
• RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse or Higher (in combination with a coding credential) preferred.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field or office work schedules