Integrity DRG Coding & Clinical Validation Analyst I​/Ii​/Iii; RHIA, RHIT, CCS, or CIC Ce

Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)

The Payment Integrity DRG Coding & Clinical Validation Analyst position requires an extensive background in acute facility-based clinical documentation and/or inpatient coding, and a thorough understanding of the current MS‑DRG and APR‑DRG payment systems. The role is responsible for reviewing medical records to ensure appropriate provider documentation supports the principal diagnosis, comorbidities, complications, secondary diagnoses, surgical procedures, and POA indicators. The analyst validates coding and DRG assignment accuracy, ensuring physician documentation aligns with hospital coded data.

• Analyzes and audits acute inpatient claims, integrating medical chart coding principles, clinical guidelines, and objectivity in audit activities.
• Applies advanced ICD‑10 coding expertise to substantiate conclusions.
• Adheres to official coding guidelines, coding clinic determinations, CMS and regulatory compliance guidelines.
• Establishes national and best‑practice benchmarks, measuring performance against them.
• Ensures accurate payment by independently utilizing DRG grouper, encoder, and claims processing platform.
• Manages case volumes and audit schedules, prioritizing workload per management direction.
• Demonstrates high standards of integrity, supporting the company’s mission and values.
• Maintains respect for member privacy in accordance with corporate policies.
• Maintains reliable attendance.
• Performs additional functions as assigned by management.

• Performs complex audits or projects with minimal direction.
• Acts as an expert in medical coding and record review, overseeing complex assignments and challenging stakeholders.
• Supports leadership in projects related to departmental strategies and initiatives.
• Participates in audits, payment methodologies, contractual agreements, and cross‑functional teams.
• Mentors new hires.
• Participates in internal/external committees.

• Provides expertise in developing audit data criteria.
• Leads training, guidance, consultation, and complex performance analysis for team members.
• Serves as an expert resource for escalations, working directly with Payment Integrity staff.
• Provides backup support for management as necessary.

Note:

This role follows a differentiated classification approach, providing guidance for employee development and promotion opportunities.

• Associate or bachelor’s degree in health information management (RHIA or RHIT) or a Nursing Degree.
• Three (3) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
• Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and knowledge of medical claims billing/pay‑ment systems.
• Maintenance of a coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC).
• Intermediate analytical and problem‑solving skills, and awareness of business analysis trends.
• Intermediate knowledge of PC, software, auditing tools and claims processing systems.

• Five (5) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
• Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and extensive knowledge of billing systems.
• Demonstrated ability across multiple skills, products, processes, and systems.
• Ability to lead initiatives with occasional guidance from management.
• Advanced analytical, problem‑solving, and judgement skills.
• Advanced knowledge of PC, software, auditing tools and claims processing systems.

• Eight (8) years of experience in claims auditing, quality assurance, or recovery auditing of MS/APR DRG coding.
• Eight (8) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and deep knowledge of billing systems.
• Demonstrated leadership skills.
• Subject‑matter expertise or consultative role in other departments.
• Independent work with lead role in key business initiatives.
• E…