Diagnosis Related Group (DRG) Coding & Clinical Audit Specialist
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Job Location:
Monthly Salary:
Experience Required:
Posted on:
6 days ago
Vacancies:
1 Vacancy
Job Summary
Location: Kondapur
Experience: 8 to 10
Work Hours: Eastern Time
Role: Diagnosis Related Group (DRG) Coding & Clinical Audit Specialist
Role Overview
The DRG Coding & Clinical Audit Specialist will be responsible for reviewing inpatient medical records and claims to ensure accurate coding clinical validation and appropriate DRG assignment. The role requires strong expertise in ICD-10 coding standards MS-DRG/APR-DRG methodologies and US healthcare reimbursement systems.
The candidate will work closely with coding audit and clinical teams to validate documentation identify discrepancies and support payment integrity initiatives.
Key Responsibilities
- Perform detailed audits of acute inpatient claims to validate accuracy of coding and DRG assignment
- Review medical records to ensure appropriate documentation supports:
- Principal and secondary diagnoses
- Comorbidities and complications (CC/MCC)
- Procedures and interventions
- Present on Admission (POA) indicators
- Apply ICD-10-CM/PCS coding guidelines DRG grouping logic and clinical validation principles during audits
- Identify coding errors documentation gaps and potential over payments/underpayments
- Ensure compliance with US regulatory guidelines (CMS coding clinic updates payer policies)
- Utilize DRG groupers encoders and claims processing tools to validate reimbursement accuracy
- Maintain productivity and meet audit turnaround timelines as per business requirements
- Support quality assurance initiatives by bench marking against industry best practices
- Collaborate with internal teams for continuous improvement in coding accuracy and audit processes
- Ensure strict adherence to data privacy and HIPAA compliance standards
Requirements
- Bachelors degree in Health Information Management Life Sciences Nursing or related field
- Professional certifications preferred:
- RHIA / RHIT
- CCS (Certified Coding Specialist)
- CIC (Certified Inpatient Coder)
- Minimum 710 years of experience in:
- Inpatient coding / DRG auditing
- Payment integrity / claims audit / RCM operations
Technical Skills & Experience
- Strong hands-on experience with:
- ICD-10-CM & ICD-10-PCS coding
- MS-DRG and APR-DRG systems
- Good understanding of:
- US healthcare reimbursement models
- Medical necessity criteria
- Provider billing guidelines
- Experience working with coding tools DRG groupers and audit platforms
- Strong analytical problem-solving and decision-making skills
- Ability to work independently and manage audit volumes efficiently
Preferred Skills
- Exposure to US healthcare clients (payer and provider side)
- Experience in payment integrity or recovery audit projects
- Knowledge of clinical documentation improvement (CDI) concepts
- Experience working with Tizetto platform (preferred / added advantage)
Required Skills:
Strong hands-on experience with: ICD-10-CM & ICD-10-PCS coding MS-DRG and APR-DRG systems Good understanding of: US healthcare reimbursement models Medical necessity criteria Provider billing guidelines Experience working with coding tools DRG groupers and audit platforms
Required Education:
Bachelors degree in Health Information Management Life Sciences Nursing or related field
