Senior Inpatient DRG Coding Analyst – Payment Integrity
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Job Summary
We are seeking a Senior Inpatient DRG Coding Analyst Payment Integrity with deep expertise in acute inpatient coding clinical validation and US healthcare claims this role you will work on complex inpatient cases for US health plans ensuring coding accuracy clinical integrity and payment correctness. You will play a key role in identifying payment variances strengthening audit defensibility and supporting compliance initiatives. This is an excellent opportunity to move into payer-side payment integrity working with advanced tools data and audit methodologies.
Key Responsibilities
- Conduct end-to-end audits of acute inpatient claims covering coding accuracy clinical validation and DRG assignment
- Validate principal and secondary diagnoses CC/MCC capture procedures (ICD-10-PCS) Present on Admission (POA) indicators and final MS-DRG / APR-DRG assignment
- Review medical records and provider documentation for completeness and accuracy
- Apply expertise in ICD-10-CM/PCS MS-DRG / APR-DRG methodologies CMS guidelines and Coding Clinic updates
- Utilize encoders DRG groupers and claims platforms to validate payment outcomes
- Apply clinical judgment and medical necessity criteria to support audit findings
- Prepare clear defensible audit documentation for internal review and appeals
- Ensure compliance with CMS HIPAA and payer guidelines
- Meet defined productivity and quality benchmarks
Requirements
Required Qualifications
- Education: RHIA / RHIT OR Nursing Degree with strong inpatient coding/audit experience
- Experience: 3 years in inpatient coding / DRG validation payment integrity / claims auditing / coding QA
- Hands-on experience: ICD-10-CM/PCS MS-DRG and/or APR-DRG acute care inpatient coding US healthcare claims and billing workflows
- Certifications (Mandatory): RHIA / RHIT CCS (AHIMA) or CIC (AAPC)
Preferred Qualifications
- Experience working with US payer-side platforms
- Knowledge or hands-on experience with TriZetto (Facets QNXT or related modules) is a strong advantage
- Exposure to post-payment audits / recovery audits appeals and provider dispute workflows
- Experience supporting US health plans / managed care organizations
Skills & Competencies
- Strong expertise in inpatient coding and DRG validation
- Excellent analytical and clinical reasoning skills
- Ability to work independently in high-volume audit environments
- High attention to accuracy and detail
- Strong written communication for audit documentation
- Up-to-date with US coding and regulatory changes
Why Join Us
- Work on high-impact US payment integrity programs
- Gain exposure to enterprise payer platforms like TriZetto
- Opportunity to grow into Senior SME Audit Lead or Consulting roles
- Be part of a quality-driven compliance-focused team
- Work with advanced healthcare data and AI-enabled platforms
Required Skills:
Production & Application Support Provide Tier 2/Tier 3 support fo Conduct end-to-end audits of acute inpatient claims covering coding accuracy clinical validation and DRG assignment Validate principal and secondary diagnoses CC/MCC capture procedures (ICD-10-PCS) Present on Admission (POA) indicators and final MS-DRG / APR-DRG assignment Review medical records and provider documentation for completeness and accuracy Apply expertise in ICD-10-CM/PCS MS-DRG / APR-DRG methodologies CMS guidelines and Coding Clinic updates Utilize encoders DRG groupers and claims platforms to validate payment outcomes Apply clinical judgment and medical necessity criteria to support audit findings Prepare clear defensible audit documentation for internal review and appeals Ensure compliance with CMS HIPAA and payer guidelines Meet defined productivity and quality benchmarks r EMR/EHR systems used by U.S. healthcare providers. Troubleshoot application interface workflow and user access issues. Perform root cause analysis and resolve incidents within defined SLAs. Support system upgrades patches and configuration changes. EMR/EHR & Clinical Workflow Support Support platforms such as Epic Cerner Allscripts Athenahealth Meditech or similar. Assist with user provisioning role configuration and access control. Understand clinical workflows including scheduling billing documentation orders and patient records. Collaborate with clinical and operational stakeholders to resolve system-related challenges. Technical Troubleshooting & Integration Analyze HL7 interfaces data feeds and system integrations. Work with APIs database queries (SQL) and application logs for troubleshooting. Coordinate with integration teams and vendors to resolve data/interface issues. Support reporting and data validation activities. Compliance & Documentation Ensure adherence to HIPAA and U.S. healthcare data security regulations. Maintain documentation of issues resolutions and knowledge base updates. Participate in audit support and access reviews when required. Client & Stakeholder Communication Communicate effectively with U.S.-based healthcare clients. Provide timely updates and manage incident escalations. Work in alignment with U.S. time zones as needed.
Required Education:
Conduct end-to-end audits of acute inpatient claims covering coding accuracy clinical validation and DRG assignmentValidate principal and secondary diagnoses CC/MCC capture procedures (ICD-10-PCS) Present on Admission (POA) indicators and final MS-DRG / APR-DRG assignmentReview medical records and provider documentation for completeness and accuracyApply expertise in ICD-10-CM/PCS MS-DRG / APR-DRG methodologies CMS guidelines and Coding Clinic updatesUtilize encoders DRG
