DRG Reviewer

🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $70.1k - $126.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Independently conduct comprehensive MS-DRG and APR-DRG coding and clinical validation reviews • Verify ICD-10-CM/PCS assignments and validate clinical diagnoses • Identify coding discrepancies, including coding errors or upcoding • Apply inpatient reimbursement rules without direct supervision • Collaborate with the Medical Director on complex cases and provide expert recommendations • Evaluate complex cases and identify opportunities to develop medical policy • Apply coding guidelines and clinical policies to determine coding accuracy and regulatory compliance • Prepare audit findings referencing AHA Coding Clinic, ICD-10 guidelines, Centene policies, and clinical guidelines • Evaluate claims and medical records for compliance with regulations, payer contracts, and company policies • Manage priorities and workflow autonomously while meeting quality and productivity standards • Assist in developing audit concepts, identifying audit opportunities, and selecting claims for review • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• 4+ years of experience performing MS-DRG and APR-DRG coding • In-patient and post-pay experience highly preferred • Associate's Degree in Health Information Management, Nursing, or related field required • 2+ years of experience performing DRG reviews for a Payment Integrity vendor or payer • 2+ years of experience using a DRG encoder/grouper such as TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar • 1+ years of experience in inpatient hospital documentation improvement preferred • One of the following required: RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), CCS (Certified Coding Specialist), CICP (Certified International Credit Professional), or CCDS (Certified Clinical Documentation Specialist) • RN state licensure and/or compact state licensure, or higher registered nurse credential, in combination with a coding credential preferred • Advanced expertise in ICD-10-CM/PCS coding • Knowledge of coding guidelines, clinical policies, inpatient reimbursement rules, regulatory requirements, payer contracts, and applicable laws • Ability to exercise discretion and professional judgment when assessing complex clinical information • Ability to prepare clear, concise, and well-supported audit findings • Ability to work autonomously and meet quality and productivity standards

🏖️ Benefits

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