The DRG Validator ensures accurate assignment of Diagnosis Related Groups (DRGs) by applying expertise in medical coding, clinical documentation, and reimbursement principles. This role promotes a culture of safety, service excellence, and compliance with all regulatory requirements.
Reports To: Manager, Operations and Coding
Key Responsibilities
Review medical records to validate accurate DRG assignments, ensuring correct case mix and compliance with federal and healthcare policies.
Analyze patient charts for discrepancies or inconsistencies in coding or documentation.
Collaborate with coding and clinical staff to resolve coding-related issues and participate in audits and quality improvement initiatives.
Conduct second reviews of focus DRGs, discharge dispositions, and Present on Admission (POA) flags prior to billing.
Communicate coding changes and clarifications to ancillary departments and medical staff, supporting education and quality improvement.
Assist in regulatory audits, recovery audit activities, and maintenance of audit software.
Research and respond to documentation and code assignment denials, coordinating with payers on DRG mismatches.
Develop and conduct educational sessions for coding and medical staff on documentation improvement and coding standards.
Create and refine coding queries in line with AHMIA physician query guidelines.
Qualifications
Education:
College degree in Health Information Management or a related field.
Experience:
At least 5 years of inpatient coding experience.
Licensure/Certification:
Credentialed coding professional required (RHIA, RHIT, CCS, CPC, or CCS-P).
Skills:
In-depth knowledge of coding guidelines, DRG assignment, UB-04 standards, and regulatory requirements.
Proficiency in medical record analysis and audit processes.
Strong communication and education skills to support documentation improvement initiatives