Centene Corporation · 7 hours ago
DRG Reviewer
United States
Full-time
Remote
Mid, Senior Level
$70K/yr - $126K/yr
4+ years expCentene Corporation is transforming the health of communities, and they are seeking a DRG Reviewer to conduct comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation. The role involves ensuring the accuracy of DRG assignment and reimbursement while collaborating with medical directors and leading evaluations of complex cases.
Hospital & Health Care
Responsibilities
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
Qualification
Required
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
Certified International Credit Professional (CICP) Required
CCDS Certified Clinical Documentation Specialist required
RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse or Higher (in combination with a coding credential) preferred
Preferred
1+ years experience of inpatient hospital documentation improvement preferred
Benefits
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Company
Centene Corporation
Centene Corporation is a leading healthcare enterprise committed to helping people live healthier lives.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Beth Johnson
President and CEO, Coordinated Care
Clyde White
President & CEO (New Hampshire Healthy Families)
Recent News
Business Journals
2024-05-06
FierceHealthcare
2024-04-28
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