DRG Validation Specialist

DRG Validation Specialist

We are seeking a knowledgeable and detail-driven DRG Validation Specialist to ensure accuracy and compliance in diagnosis-related group (DRG) assignment and inpatient medical record coding. This role plays a key part in supporting revenue integrity, reducing audit risk, and ensuring accurate representation of patient acuity and clinical documentation.

Key Responsibilities

• Perform comprehensive DRG validation reviews on inpatient medical records to ensure accurate code assignment, clinical justification, and regulatory compliance.

• Validate ICD-10-CM, ICD-10-PCS, and sequencing accuracy to support compliant DRG assignment and reimbursement.

• Identify and address discrepancies related to clinical documentation, coding, and DRG grouping; initiate clarification queries when necessary.

• Analyze clinical indicators and documentation to ensure support for complications/co-morbidities (CCs/MCCs) and medical necessity.

• Collaborate with Coding, CDI, and Revenue Cycle teams to resolve variances and ensure alignment with documentation and reporting requirements.

• Participate in internal and external audit processes and support appeals for denied or challenged DRG assignments.

• Maintain required productivity benchmarks and exceed accuracy quality metrics (typically ≥95%).

• Stay current with changes in coding guidelines, DRG methodology, payer rules, and regulatory updates.

• Participate in training, education, special projects, and process improvement initiatives.

Qualifications

• Required certification: CCS, RHIT, RHIA, or CPC with inpatient coding experience.

• Minimum experience: 3+ years inpatient coding experience; DRG validation or audit experience strongly preferred.

• Strong working knowledge of:

  • ICD-10-CM/PCS coding

  • DRG payment methodologies (MS-DRG, APR-DRG, etc.)

  • CMS and payer-specific audit criteria

• Prior experience with CDI programs, audit software, or EMR/EHR systems preferred.

Skills & Competencies

• Exceptional accuracy and attention to detail

• Strong critical thinking and clinical interpretation skills

• Ability to interpret complex documentation and clinical terminology

• Effective communication and collaboration across departments

• Strong organizational and time-management abilities